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It was disclosed that the passengers had not been briefed regarding emergency evacuation of the aircraft and that only two of the survivors were familiar with the location of the emergency exists or how they operated. Three of the four survivors, one a flight crew member, managed to exit through the crew entrance door which, because of incorrect emergency procedures, could only be raised a few inches from the flight deck. One survivor is believed to have exited through the aft right emergency window exit. One of the survivors stated that he saw one victim attempting to kick a window out in an effort to evacuate the aircraft. Although a briefing was not required, it is believed that had all personnel aboard had adequate knowledge of emergency evacuation procedures, additional lives might have been saved and the injuries sustained by the survivors would have been of a less serious nature.
It is realized that no on-flight radio navigation malfunction occurred during the portion of the flight conducted under instrument flight rules and that the provisions of SR-445 were not applicable to this flight. However, had the crew of Slick 40Z notified ATC personnel of the known glide slope receiver outage, it is believed that the maximum amount of assistance consistent with the equipment at the controller's disposal would have been provided.
Probable Cause
The Board determines the probable cause of this accident was the continuation of an instrument approach after adequate visual reference was lost below authorized minimums. Inadequate monitoring of the instrument approach by the PAR controller was a contributing factor.
BY THE CIVIL AERONAUTICS BOARD
/s/ ALAN S. BOYD
Chairman
/s/ ROBERT T.MURPHY
Vice Chairman
/s/ G. JOSEPH MINETTI
Member
/s/ WHITNEY GILLILLAND
Member
CHAN GURNEY, Member, did not take part in the adoption of this report.
