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Aircraft Accident Case Study

some time following the 1991 incident the director of flight technical programs had voiced disagreement about the need to change the FEF stall recovery procedures. The director of flight technical programs continued to use the old stall recovery procedures and was eventually put in charge as a fllight standards manager. In this position he trained the accident PNF, who in turn, trained the accident PF. The Safety Board notes that although some provisions of the revised procedure were used, the manner in which they were used confirmed that the flightcrew was attempting the original, minimum altitude loss stall recovery. This ultimately resulted in incorrect procedures being used to recover from a stall maneuver. 16. ABXs failure to require completion of a functional evaluation flight by sundown or to establish adequate limitations on ambient lighting and weather conditions led the flightcrew to attempt the stall series in the absence of a natural horizon.ABX had weather minimums for FEF takeoffs but no minimums were established for maneuvers performed at higher altitudes and beyond the vicinity of the airport, such as the stall series. Further ABX guidance for performing the clean stall maneuver specified a minimum altitude of 10,000 feet agl and a maximum altitude of 15,000 feet msl. However, no requirements were established for ambient lighting conditions, visual references, or distance from cloud tops. This direction, or lack there of, went further into management by the director of flight technical programs stating to Safety Board Investigators that he preferred the stall series not to be performed in IMC. In contrast, subsequent Safety Board investigation of flight manuals from two other air carriers restricted stall series maneuvers to being performed in VMC with a visible horizon. Manuals of two airplane manufacturers limited the stall maneuver to daylight hours. The lack of guidance by ABX management put the aircrew i...

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