The Fifth Circle: The crash of Northwest Airlink flight 5719
On the first of December 1993, a commuter flight on approach to a rural airport in northern Minnesota struck a hilltop short of the runway, killing all 18 passengers and crew on board. When investigators with the National Transportation Safety Board arrived at the Iron Range town of Hibbing to determine the cause of the crash, they found all the hallmarks of a classic case of controlled flight into terrain: a descent that was too fast, poor cockpit communication, a failure to monitor altitude until it was too late. But when trying to explain why the crew had made these mistakes, NTSB investigators found themselves drawn down the increasingly disturbing rabbit hole of the captain’s personal life. What they discovered painted a picture of a man with a personality incompatible with safety. One thing was clear: the crash of Northwest Airlink flight 5719 did not begin with the crew’s procedural errors, but with a complex set of interpersonal relationships that far predated the fatal flight.
In the backwoods of northern Minnesota, deep in the rolling hills of the Iron Range, lies the town of Hibbing. Built to support the world’s largest open pit iron mine, the town of about 18,000 (16,000 today) is perhaps best known for being the birthplace of both Bob Dylan and Greyhound Bus Lines. As the most populous town in Minnesota’s northern interior, Hibbing also plays host to Range Regional Airport, which serves as an important connection with the metropolitan areas far to the south.
The only airline serving Range Regional Airport in the 1990s was Northwest Airlink. The real name of the company was Express II, but it operated under a contract with Minneapolis-based Northwest Airlines, allowing customers to book its flights through Northwest under the brand name Northwest Airlink. Using a fleet of small to midsized twin turboprop aircraft, Express II served towns all over the north central United States, and particularly in South Dakota, Iowa, and Minnesota, providing regular flights to many locales where it was the only scheduled airline.
On the evening of the 1st of December 1993, one of Express II’s scheduled flights was flight 5719 (operated under the Northwest Airlink branding) from Minneapolis-Saint Paul International Airport to Range Regional Airport in Hibbing. The aircraft used on this route was a Jetstream 3100, a small British-made twin turboprop capable of carrying up to 19 passengers. Tonight, 17 passengers were booked on the flight, as well as two pilots: 42-year-old Captain Marvin Falitz, and 25-year-old First Officer Chad Erickson. Erickson was a new hire with 2,000 flight hours but only 65 on the Jetstream 3100, far less than the seasoned Captain Falitz. Still on his probationary period, where captains would report on his performance, he had taken careful notes on all the procedures and was keen to impress.
In contrast to his young, cheerful, First Officer, Captain Falitz was not having a good day. He was working as a reserve captain, which meant he could be called up unexpectedly to conduct flights that needed a last minute addition to the crew, and this was one such trip. The three-day flight sequence to which he’d been assigned would wipe out his expected day off on December 2nd, and he had to cancel his plans. He was so annoyed by the schedule change that he filled out an Air Line Pilots Association grievance form, which he left behind in his room, where he presumably planned to sign and postmark it when he returned.
That wasn’t his only bad experience that day. Earlier on the 1st, he had to “deadhead” — ride as a non-paying passenger — to International Falls. When he tried to board the plane, he found that his authorization from Express II to ride as a passenger hadn’t come through. He asked a customer service agent to resolve this for him as quickly as possible, but she told him that this was supposed to be his duty, not hers. With rising anger, he berated her until she gave in, calling to confirm his authorization just in time for him to board the flight. The interaction left the agent shaken, and her supervisor urged her to file a formal complaint against him.
Later that evening, Falitz arrived in Minneapolis to command flight 5719 to Hibbing, whereupon he and First Officer Chad Erickson set about preparing the plane for departure. While a bewildered ramp agent looked on, Falitz berated Erickson for failing to perform the pre-flight inspections correctly, resulting in his failure to discover that the landing lights weren’t working. The flight had to be delayed while mechanics swapped out the bulbs. Then, just as the passengers were about to get on the plane, he halted boarding so he could hang up his coat. He then sat down to calculate the plane’s weight and center of gravity, during which he discovered that the plane was 130 pounds over the maximum takeoff weight. He yelled out the window to a ground handler that the plane was too heavy, and a passenger voluntarily disembarked to get the weight within limits. After the lucky passenger retrieved their baggage and returned to the terminal, flight 5719 — now with 18 occupants instead of 19 — finally left Minneapolis at 6:52 p.m., 42 minutes late.
At 7:32 p.m., Captain Falitz sat down with First Officer Erickson to hash out their approach plan. The wind that night favored the southeast-pointing runway 13. That would present a little bit of extra difficulty, because runway 13 did not have an instrument landing system (ILS), which would make it easier to land amid the low clouds that blanketed the region. Only runway 31 — the same runway in the opposite direction — had such a system. In order to land into the wind while still taking partial advantage of the ILS, Captain Falitz elected to perform a difficult non-precision back course approach to runway 13. Although they were not landing on runway 31, it was still possible to use part of that runway’s ILS; specifically, the localizer, which broadcasts a narrow bidirectional beam that the pilots can follow to align with the runway. Flying at the localizer from the wrong direction, known as a back course approach, would require special adjustments to prevent their navigational instruments from reversing, resulting in a significant increase in workload. However, the other component of the ILS — the glide slope, which guides the plane down on the appropriate descent angle — would not be usable on a back course approach, forcing the pilots to descend in a series of planned step-downs at particular distances from the runway. To make matters worse, the back course approach to runway 13 involved a relatively rare procedure known as a DME arc, which required them to fly a long semi-circular curve while keeping a constant distance from the airport’s locator beacon. And on top of that, the reported cloud base was only 420 feet above ground level, approximately equal to the minimum descent altitude, the lowest they could fly without establishing visual contact with the runway. All of these factors came together to make this particular approach to Hibbing extremely stressful for the flight crew.
At 7:36, Captain Falitz instructed First Officer Erickson to contact the Express II operational base in Hibbing to report their imminent arrival.
Erickson keyed his mic and said, “Ops, seven nineteen’s in range.”
“Say Hibbing,” said Falitz.
“Hibbing, go ahead,” said the ops center.
“Yeah, Hibbing, this is seven nineteen, in range, positive fuel,” said Erickson.
“Okay, in range, positive fuel, see you in a bit,” the ops center replied.
Falitz was clearly not satisfied with Erickson’s performance. “Saying ‘ops,’ they’re not gonna answer,” he added gratuitously, “because who’s supposed to answer — Sioux City Ops, Hibbing Ops, Duluth Ops?”
“Right,” Erickson muttered.
Around 7:40, Captain Falitz decided to change their approach plan because other pilots landing at the airport had reported that they experienced light to moderate ice accumulation while descending through the cloud layer below 8,000 feet. Because ice poses a significant danger to airplanes, especially small ones like the Jetstream 3100, Captain Falitz decided that he was going to try to spend as little time as possible inside the cloud layer where ice could form. To accomplish this, he planned to remain above 8,000 feet for as long as possible before descending very rapidly through the area of icing conditions (see below), a technique not described in any official procedure but commonly used by pilots at Express II.
However, by this time Falitz had already performed the approach briefing, in which he laid out the approach procedure for First Officer Erickson. Instead of telling Erickson about the change of plans, he just kept flying at 8,000 past the point they had earlier agreed to descend. Noticing that Falitz was staying at 8,000 feet, Erickson asked, “You gonna stay up here as long as you can?”
“Yes,” came Falitz’s curt reply.
Instead of descending to an intermediate altitude as described in the procedure, Falitz kept them high almost all the way through the DME arc, then pitched down and entered a descent of 2,250 feet per minute, more than twice the maximum prescribed by both company rules and federal regulations. First Officer Erickson was obligated to call out any descent rate greater than 1,000 feet per minute, but he said nothing. In rapid fire sequence, Falitz gave Erickson orders, asked for approach information, and ran through checklists. They soon passed over the final approach fix, the last navigational waypoint before the airport, still 1,000 feet too high and descending at twice the normal rate. Proper procedures obligated them to go around due to an unstable approach, but because Falitz was descending this way on purpose, they didn’t.
Moments later, Erickson called out “one to go,” meaning they were 1,000 feet above their last step height before landing. If they were too far from the airport upon reaching the step height of 2,040 feet, they would need to level off.
“To what alt — to 2040, okay,” said Falitz.
“2040,” Erickson confirmed. But with that altitude just seconds away, Falitz said to Erickson, “Did you click the airport lights? Make sure the common traffic advisory frequency is set.” At Range Regional Airport, there was no control tower, so pilots had to activate the runway lights by clicking the microphone key seven times while tuned to the airport’s common frequency. Without replying to Falitz, Erickson clicked his microphone seven times.
“Click it seven times?” Falitz asked.
“Yup, yeah I got it now,” said Erickson. Neither pilot noticed that they had passed through their step down altitude and were still descending at more than 1,000 feet per minute. Seconds later, without warning, the right wing of the Jetstream 3100 struck a pine atop a ridge in a disused mine, slicing off the tips of both the wing and the tree. The pilots were caught so completely by surprise that they never uttered so much as a scream. The plane clipped off the tops of several aspen trees, cleared a ravine, rolled over, and smashed into the ridge on the opposite side, sending debris cartwheeling up and over the summit. In less than five seconds, it was all over: all 18 passengers and crew died instantly on impact.
By 7:55, flight 5719 should have landed, and as Express II ground handlers waited without any sign of the plane, the ops center began to fear the worst. The airline soon alerted emergency services, and a search and rescue operation was launched into the frigid night to locate the missing plane. Approximately one hour later, first responders located the wreckage atop a ridge 5.4km short of runway 13. They arrived to a gruesome scene: bodies had been ejected from the plane, surrounded by Christmas gifts torn from the passengers’ bags, and the snow was stained red with blood. It was obvious that there were no survivors.
The next phase of the response now fell to the National Transportation Safety Board, whose investigators soon arrived at the rural crash site amid subzero temperatures. To seasoned investigators, physical evidence indicated that the plane had struck the ground at a shallow angle, apparently under control. In all likelihood, that made Northwest Airlink flight 5719 the latest case of controlled flight into terrain, or CFIT, one of the most common types of accidents involving airplanes of any size. But every CFIT is unique — the black box would have to reveal how.
Although the small commuter plane didn’t have a flight data recorder, the cockpit voice recorder in combination with the radar track revealed the basic sequence of events. The precipitating error was the failure of the captain to reduce the rate of descent in a timely manner, causing the aircraft to descend through the minimum descent altitude (MDA), the lowest height above terrain allowed in that area. After putting the plane into a steeper than normal descent to avoid spending time in icing conditions, he simply forgot to rein it in once the plane reached the proper altitude, and the first officer failed to warn him.
Tragically, the plane was not equipped with a ground proximity warning system (GPWS), unlike larger aircraft, which had been required to have them since 1975. Had the accident aircraft been equipped with a GPWS, it would have sounded a loud “PULL UP” alarm approximately 21 seconds before impact, and the crash almost certainly would not have occurred. Ground proximity warning systems had already been made mandatory for aircraft in the 10–19 seat range with a deadline in April 1994, but with the deadline a little less than five months away, Express II still hadn’t installed the system on its fleet of Jetstream 3100s.
On any aircraft, especially one without a GPWS, it is critical that the crew maintains altitude awareness at all times. Much of this task falls to the pilot not flying — in this case, the first officer — who must monitor altitude and descent rate and make callouts at certain thresholds throughout the approach. Proper procedure called for him to announce any sink rate greater than 1,000 feet per minute; 1,000 feet and 300 feet above any assigned altitude; 500 and 100 feet above the MDA, as indicated on their approach charts; and the attainment of any assigned altitude or the MDA. Remarkably, First Officer Erickson made only one of these required callouts in the minutes before the crash. When he did say “one to go” at 1,000 feet above their final step down, Captain Falitz started to ask “to what altitude,” which indicated that he was not initially aware of the height of the aircraft or when he was supposed to level off next.
With Captain Falitz lacking altitude awareness, he would have relied on First Officer Erickson to tell him when they were about to reach the step down altitude of 2,040 feet, and after that, the MDA, which was 1,780 feet, or about 250 feet above the high ground with which the plane collided. But immediately after Erickson’s “one to go” callout, Falitz gave him a totally unrelated task: activating the runway lights. At this point, only 37 seconds remained until impact with the ground, and almost all of this time was consumed by the activation of the airport lighting, a task which should have been completed earlier in the approach. With both crewmembers inexplicably distracted by this simple task, and the hill shrouded in darkness, no one realized that disaster was just seconds away.
Still, some important questions remained. Why did Captain Falitz decide to descend at such a dangerous rate just to avoid icing? And why did neither pilot express any doubt about this decision or voice any concern about their altitude as the plane hurtled toward the ground?
Regarding the first question, interviews with Express II pilots revealed that although this technique to avoid icing conditions was against regulations, they used it frequently, and had taught it to each other on an informal basis. In reality, a rapid descent through icing conditions was not necessary; the Jetstream 3100 was equipped with a capable de-icing system that could easily remove any light to moderate ice buildup on the leading edges of the wings and tail.
When asked about the technique and its use by Jetstream 3100 pilots, the Federal Administration (FAA) inspector tasked with overseeing Express II stated that he was totally unaware of the dangerous practice. This was probably because he was based in Des Moines, Iowa, a city which was not served by Express II. In order to monitor the conduct of Express II pilots, he had to drive over 160 kilometers (100 miles) to either Mason City or Cedar Rapids, catch an Express II flight, and watch how the crew handled the airplane. Because it was such a hassle to monitor flights in this way, he had only ever done so four times, which was insufficient to notice the pattern of violations.
In order to answer the second question — why neither pilot noticed that they were flying their plane into the ground — the NTSB decided to learn more about the crew. This line of inquiry would lead investigators to troubling conclusions which would paint the entire accident sequence in a new light.
First Officer Erickson was by all accounts a competent and dedicated pilot. During flight school, he was the only one out of five classmates to pass his initial simulator check on the first attempt. He soon landed a position at Express II, which he described as his dream job. His level of knowledge was excellent; he even prepared flash cards with information about every airport used by Express II, some of which were found in the wreckage of flight 5719. But this didn’t mean there weren’t certain pressures being exerted on the young first officer. He was still in his probationary period, and he worried that a bad performance review from a captain could seriously damage his career. He had spent $8,500 of his own money to train for a position where he could expect to make only $18,000 a year, and he was extremely motivated not to lose out on that investment.
Captain Falitz turned out to be a totally different story. From the very beginning of his training, his behavior had been raising red flags. In 1980, he failed his initial attempts to acquire both his commercial pilot and flight instructor certificates. When training to fly the Saab 340, his instructor wrote that Falitz communicated poorly with other crewmembers, and that while he liked him as a person, he was headstrong, argumentative, and thought he was always right, qualities which made him difficult to teach. During this training, he once shut down the wrong engine during a simulated engine failure due to poor communication with the first officer.
Subsequently, in 1987, Falitz failed an oral exam during a routine proficiency check. In 1988, he failed a check ride — a flight where an instructor known as a check airman graded his performance. After undergoing a few hours of remedial training, he tried again with the same check airman later that same day, and this time he passed. But in 1992, he failed another check ride. Again, he passed after redoing the check ride with the same instructor later that very day. Finally, in May 1993, 6 months before the accident, he failed a third check ride — something few pilots manage without losing their jobs. Among the deficiencies noted were poor communication (he didn’t check whether the first officer obeyed his commands); incorrect procedures while holding (he entered the holding pattern too fast); and poor knowledge of stalls (he didn’t know the stall recovery procedure). Once again, he went to “retraining” and passed on his second attempt.
In addition to his apparently subpar airmanship skills, there were some serious problems with the captain’s personality. After his most recent check ride, the check airman commented that while his performance was satisfactory, he was “bothered” by Falitz’s attitude. He was hardly the only one to feel this way. His personnel file revealed multiple accusations of sexual harassment against female employees, at least one case of unauthorized sleeping while in flight, and several other violations including but not limited to starting the engines without permission, delaying a flight to eat breakfast, and destroying a cargo load report. Most disturbingly, one first officer stated that Falitz physically struck him after he accidentally left the intercom on. The first officer even shared this story with Chad Erickson, which probably left him fearful of Falitz before the two men ever met. In fact, five out of six Express II first officers interviewed by the NTSB stated that they found Captain Falitz intimidating. When Erickson showed up for flight 5719, he was likely already terrified that any perceived slight or minor mistake would cause Falitz to write a bad review and torpedo his career. Within minutes, those worst fears were realized when Falitz chewed him out for missing a step on the pre-flight checks.
There was also plenty of evidence that Falitz was in a bad mood during the time leading up to the ill-fated flight. According to those who knew him, he had been forced to switch to flying smaller airplanes, with a complementary 12% pay cut, in order to stay in Minneapolis instead of getting rebased to one of the dead-end towns where Express II asked most of its pilots to live. He had also been issued with frequent complaints and verbal reprimands for reasons which he and his fellow pilots felt were unjust, such as refusing to fly planes with mechanical defects and calling in sick under what the airline insisted were “suspicious circumstances.” He had begun to suspect that the airline was retaliating against him for his outspokenness and his role in the pilots’ union, which was threatening to strike at the time. These issues left him upset with the way the airline was treating him, and he was privately considering moving to a different company or even leaving aviation altogether. He was so mad at the airline that he allegedly made rough control inputs in order to scare passengers away from flying Northwest Airlink. People who interacted with him the day before the flight said he sounded depressed, and he complained that the airline had repeatedly violated his contract. Then came the poorly timed schedule change, the altercation with the customer service agent, the mechanical problem with his plane, the excess weight, the late departure, the bad weather, and the highly complex approach. By the time flight 5719 neared Hibbing, Falitz’s brain was a seething stew of anger, frustration, bitterness, and resentment.
The way that all these factors manifested on the flight deck was critical to the sequence of events. Almost all of Falitz’s interactions with Erickson consisted of commands and corrections, most of which related to tasks that Erickson was perfectly capable of completing himself, making his place in the cockpit hierarchy unmistakable. Falitz criticized and micromanaged everything Erickson did, including such common tasks as how to set up the radios, how to tune the navigational instruments, when to perform checklists, and even how to clip his approach chart in place. Not only did this helicopter parenting distract Falitz from the job of flying the airplane, it also instilled in First Officer Erickson even greater fear and self-doubt, causing him to withdraw into himself in an effort to avoid speaking to Falitz. The constant stream of criticism of his every action led him unconsciously to avoid taking any action at all. Falitz had so thoroughly intimidated Erickson that he simply shut down and ceased performing the duties which were meant to prevent controlled flight into terrain.
NTSB investigators were stunned that a pilot as toxic as Marvin Falitz was allowed to keep flying. The three failed check rides and the pattern of sexual harassment each by themselves constituted sufficient cause to fire him. But when the NTSB interviewed Express II’s Director of Operations, they discovered that the man who could have fired Falitz had no knowledge of his terrible training record. In fact, although the DO was tasked with monitoring crew training, he was based in Minneapolis and the training took place in Memphis. He had never traveled to Memphis to observe training or look at pilots’ training records, nor did he seem to be aware that this was part of his job description. This lack of knowledge was especially remarkable considering that the DO personally knew Falitz and had even counseled him on some of his social issues. Although he was aware of Falitz’s inability to get along with other people, he apparently never connected this to his ability, or lack thereof, to uphold an acceptable level of safety. Rigorous training can iron out most pilots’ personality faults, but some people are simply incompatible with the requirements of the job, and weeding them out is a critical aspect of maintaining a safe operation which Express II grossly neglected. To his friends, Marvin Falitz may have seemed like a good person with a few personality quirks, and many of his acquaintances described him as highly intelligent. And who doesn’t have a few unresolved emotional issues adding a little bit of spice to their life? But in aviation, an anger management problem is a safety problem, and the crash of Northwest Airlink flight 5719 clearly showed why.
As a result of its investigation, the NTSB recommended that the FAA issue guidance to help its inspectors monitor pilot training and on-the-job performance, among other suggestions related to FAA procedures. The NTSB also re-iterated a recommendation, made after the crash of Bar Harbor Airlines flight 1808, asking the FAA to require airlines to provide approach charts for both crewmembers. (On flight 5719, the first officer was using the crew’s only set of approach charts, reducing the captain’s awareness of their position.) After April 1994, as originally scheduled, all airplanes with over 10 seats had to have ground proximity warning systems installed. And the accident to this day is used as a case study when teaching flight crews about the importance of human interactions in maintaining a high standard of safety. But the central problem — the failure to weed out bad pilots — continues to kill. In 2019, Atlas Air flight 3591, a Boeing 767 operating a cargo flight on behalf of Amazon Air, crashed near Houston after the first officer became spatially disoriented and flew the jet into the water. All three crewmembers were killed. The NTSB found that the first officer had a long history of training difficulties, including wildly inappropriate responses to unexpected events and a total lack of self-awareness regarding his skills, but he had somehow managed to retain his job due to insufficient scrutiny of his record. As regional airlines and cargo carriers continue to scrape the bottom of the barrel to find enough pilots — a problem which will surely return after the end of the Covid-19 pandemic — it is worth questioning whether, 26 years after the crash of Northwest Airlink flight 5719, enough systems are in place to prevent another Marvin Falitz from taking the wheel of a passenger plane.
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