NTSB CAROL · Event
Event CHI91DEX03
Aircraft involved
Probable cause & findings
EXCEEDING THE AIRCRAFT'S PROPER DESCENT RATE BY THE PILOT IN COMMAND. FACTORS RELATED TO THE ACCIDENT WERE INOPERATIVE RUNWAY EDGE LIGHTS, PROPER ALIGNMENT NOT ATTAINED, IMPROPERLY PLANNED APPROACH, AND INADEQUATE FACILITY MAINTENANCE.
Factual narrative
THE PILOT MADE A NIGHT VISUAL APPROACH TO AN AIRPORT WHERE THE RUNWAY LIGHTS WERE INOPERATIVE. THE LOCAL PROCEDURE FOR MAKING NIGHT APPROACHES TO THE AIRPORT WHEN THE LIGHTS ARE INOPERATIVE IS TO LINE UP THE AIRPORT ROTATING BEACON WITH THE MARKER LIGHT ON A GRAIN BIN ONE HALF MILE FROM THE AIRPORT, START A DESCENT, AND WAIT FOR THE AIRCRAFT LANDING LIGHTS TO ILLUMINATE THE RUNWAY. HE WAS HIGH ON THE FIRST APPROACH AND EXECUTED A GO AROUND. ON THE SECOND APPROACH HE WAS HIGH AND TO THE LEFT, BUT HAD ESTABLISHED A HIGH RATE OF DESCENT, AND FAILED TO CORRECT FOR THIS CONDITION PRIOR TO GROUND IMPACT 20 FEET LEFT OF THE RUNWAY AT APPROXIMATELY MID FIELD. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1991_CHI91DEX03.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
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