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Human Factors Report Propulsion System Malfunction Plus Inappropriate Crew Response

The task report presented herewith was undertaken by Aerospace Industries Association (AIA) and The European Association of Aerospace Industries (AECMA) at the request of the U.S. Federal Aviation Administration (FAA) in response to a U.S. National Transportation Safety Board (NTSB) recommendation arising from the 13 December 1994 turboprop-airplane accident at Raleigh-Durham, North Carolina, U.S., which resulted in fatal injuries to 13 passengers and two crewmembers. The NTSB findings in this event strongly suggested that a warning light intended to indicate the activation of a recovery function was falsely interpreted as an engine failure and led to inappropriate crew action. The FAA recognized that there were additional data suggesting that this accident was one of a number of similar accidents, and that a study would be appropriate to look into all commercial transport accident histories where an inappropriate crew action may have been taken in response to what should have been a benign propulsion system malfunction.

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