Prevailing Cultural / Organizational Factors

The accident board cited Birgenair's lack of a formal Crew Resource Management (CRM) training program as an additional factor in this accident. It is not known if this was a requirement of the Turkish regulators at the time of the accident, but it was a formal requirement of the FAA.

Further, manufacturer's maintenance procedures specified that for extended out of service periods (such as extended maintenance), pitot covers should be installed. Additionally, the same maintenance procedures specified that following extended maintenance periods, the pitot-static system should be checked for proper operation prior to airplane return to service. It was established by the investigation that the pitot covers were not installed, and that the pitot-static system was not functionally checked, per the manufacturer's recommended maintenance procedures, before the airplane was returned to service.

Back to top