WHILE ON A LOCALIZER BACK COURSE APPROACH THE AIRPLANE COLLIDED WITH TREES AND
THE TERRAIN APRX 3 MI FROM THE RUNWAY THRESHOLD. THE CAPTAIN DELAYED THE START
OF THE DESCENT THAT SUBSEQUENTLY REQUIRED AN EXCESSIVE DESCENT RATE TO REACH THE
FAF AND MDH. THE CAPTAIN'S ACTIONS LED TO DISTRACTIONS DURING CRITICAL PHASES OF
THE APPROACH. THE FLIGHTCREW LOST ALTITUDE AWARENESS AND ALLOWED THE AIRPLANE TO
DESCEND BELOW MANDATORY LEVEL OFF POINTS. THE CAPTAIN'S RECORD RAISED QUESTIONS
ABOUT HIS AIRMANSHIP AND BEHAVIOR THAT SUGGESTED A LACK OF CREW COORDINATION
DURING FLIGHT OPERATIONS, INCLUDING INTIMIDATION OF FIRST OFFICERS. COMPANY
MANAGEMENT DID NOT ADDRESS THESE MATTERS ADEQUATELY. THE AIRLINE'S FLIGHT
OPERATIONS MANAGEMENT FAILED TO IMPLEMENT PROVISIONS TO ADEQUATELY OVERSEE THE
TRAINING OF THEIR FLIGHTCREWS AND THE OPERATION OF THEIR AIRCRAFT. FAA GUIDANCE
TO THEIR INSPECTORS CONCERNING IMPLEMENTATION OF OPS BULLETINS IS INADEQUATE AND
HAS FAILED TO TRANSMIT VALUABLE SAFETY INFORMATION AS INTENDED TO AIRLINES.
Probable Cause
THE CAPTAIN'S ACTIONS THAT LED TO A BREAKDOWN IN CREW COORDINATION AND THE LOSS
OF ALTITUDE AWARENESS BY THE FLIGHTCREW DURING AN UNSTABILIZED APPROACH IN NIGHT
INSTRUMENT METEOROLOGICAL CONDITIONS. CONTRIBUTING TO THE ACCIDENT WERE: THE
FAILURE OF THE COMPANY MANAGEMENT TO ADEQUATELY ADDRESS THE PREVIOUSLY
IDENTIFIED DEFICIENCIES IN AIRMANSHIP AND CREW RESOURCE MANAGEMENT OF THE
CAPTAIN; THE FAILURE OF THE COMPANY TO IDENTIFY AND CORRECT A WIDESPREAD,
UNAPPROVED PRACTICE DURING INSTRUMENT APPROACH PROCEDURES; AND THE FEDERAL
AVIATION ADMINISTRATION'S INADEQUATE SURVEILLANCE AND OVERSIGHT OF THE AIR
CARRIER. (NTSB REPORT AAR-94/05)