Hawker Crash: Chain Of Culpability

I found Hart's opening statement particularly noteworthy because he set aside any pretense of Washingtonian niceties and characterized the accident flight as miserably failing to meet its passengers' expectations of a safe flight. Hart said, "...we found a flight crew, a company and FAA inspectors who fell short of their obligations in regard to safety." Hart said that not only did the crew ignore company procedures and fly an unstabilized approach with an unapproved flap configuration, they also ignored required checklists and callouts, and had an unstructured, inconsistent and incomplete approach briefing. Hart said the company had questionable hiring, training, scheduling and other practices. He highlighted the captain only getting 40% of the answers right on a test about Crew Resource Management (CRM) during training, yet the company scoring it as 100% correct. "It is not surprising that CRM issues featured prominently in the accident flight," Hart said.

The NTSB determined that the probable cause of the accident was "...the flight crew's mismanagement  of the approach and multiple deviations from company standard operating procedures, which placed the airplane in an unsafe situation and led to an unstabilized approach, a descent below MDA without visual contact with the runway environment, and an aerodynamic stall. Contributing to the accident were Execuflight's casual attitude toward compliance with standards; its inadequate hiring, training, and operational oversight of the flight crew; the company's lack of a formal safety program; and the FAA's insufficient oversight of the company's training program and flight operations." Even though the NTSB's final report couldn't be ready at the time of the board meeting, plenty of information was available to tell us what likely happened.

The accident airplane was manufactured by British Aerospace in 1979, and received its airworthiness certificate from the FAA after being imported to the U.S. It was added to Execuflight's operating certificate on November 8, 2010. According to information gathered by investigators, it had flown approximately 19,947 hours and had a total of 11,075 cycles (a cycle is a takeoff and landing).

The HS-125-700A was powered by two Honeywell TFE-731 engines, rated at 3,700 pounds of thrust each. Typical long-range cruise at FL390 was 390 knots true airspeed (KTAS), with a high-speed cruise at FL350 of 425 KTAS.

The airplane wasn't required to be equipped with a flight data recorder. Because it was being operated under Part 135, and was a multi-engine turbine-powered airplane with six or more passenger seats for which two pilots were required, and was built before April 7, 2010, it had to be equipped with a cockpit voice recorder (CVR) that recorded at least the latest 30 minutes of sounds. The recorder on the accident airplane was an older model, which used a continuous loop of magnetic tape. It was capable of recording four channels of audio, although only three were used. The first officer's headphone microphone was recorded on channel one, a mic that picked up cockpit sounds was on channel two, and the captain's headset mic was on channel three. All three channels had poor quality, with a loud continuous tone of about 400 cycles-per-second interfering with the voices. This made it difficult for investigators to reconstruct what was going on. As a result of this accident, the NTSB called on the FAA to investigate the reasons for the CVR problem, and do something to be sure aircraft operators comply with regulations that require that CVRs work as intended. If only someone had listened to a recording made on the Hawker's CVR sometime before the accident flight, presumably the problem would have been discovered, could have been corrected and investigators would have had more information regarding what the pilots were doing.

The NTSB took issue with the FAA for not requiring some sort of data recorder on airplanes like this one. It also said both pilots likely were fatigued because of their duty schedules, but couldn't determine to what extent this contributed to the accident. It questioned the adequacy of training received by the accident crew and other pilots regarding stabilized approaches, flying a continuous descent final approach, and ensuring that weight and balance information they're using is accurate. Execuflight said the accident airplane was within loading limits, even if the NTSB wasn't sure.

The NTSB faulted the FAA for the high workload its principal operations inspectors face when overseeing Part 135 operators, and their inability to fly with crews of the operators they oversee often enough to identify pilots who aren't complying with standard operating procedures.

The captain was 40 years old. He was born in Columbia, and flew for companies there until April 2014. In May 2014, he got a job as a Hawker 800 pilot for a U.S. company. That employment ended in 2015, and he was subsequently hired by Execuflight. Investigators found that in June 2014, he had violated the FARs by not descending as instructed by ATC. A letter of correction was issued by the FAA and the pilot underwent remedial training. He held an FAA ATP certificate for single-engine and multi-engine land with an HS-125 type rating. His total time was 6,170 hours with 1,020 hours in the HS-125.

The first officer was 50 years old. He was born in Italy. His date of hire with Execuflight was June 1, 2015. He had previously flown as a first officer on Boeing 737s, and before that for charter operators as a first officer on Hawker and Lear airplanes. He was in the Italian Air Force from 1987 to 1991. He held an FAA ATP certificate for multi-engine land airplanes, with commercial privileges for single-engine land airplanes. He had type ratings for the HS-125 and B737, and a second-in-command type rating for Learjets. In addition, he was restricted from flying circling approaches in B737s unless VFR. His total time was 4,382 hours, with 482 in HS-125 airplanes.

The pilot and first officer were teamed for flights to six cities over a two-day period beginning the day before the accident. The sequence began and was supposed to end at Execuflight's home base at Fort Lauderdale Executive Airport (KFXE), Fort Lauderdale, Florida. Flights on the first day were uneventful.

Execuflight's records indicated the pilots had flown with each other three times within the previous 90 days for about 32.5 flight hours. According to Execuflight records, neither pilot had experience operating into or out of KAKR. They were supposed to be familiar with every airport they'd be going to on revenue flights.

On the day of the accident, the first flight of the day departed Cincinnati Municipal Airport Lunken Field (KLUK) in Cincinnati, Ohio, at about 11:03 a.m., and arrived at Dayton-Wright Brothers Airport (KMGY) in Dayton, Ohio, a half-hour later. While at KMGY, the captain filed an IFR flight plan to Akron Fulton International Airport (KAKR). Planned flight time was 34 minutes, the cruise altitude was 17,000 feet MSL, cruise speed was 382 knots, and the planned departure time was 1:30 p.m. While at KMGY, the airplane was fueled with 410 gallons (2,788 pounds) of Jet A, to fill both wing tanks to capacity.

At 1:49 p.m., the captain sent a "doors closed" text message from his cell phone to the company. At 1:54, the crew contacted flight service to obtain their IFR release to KAKR. They were given the IFR clearance, but told to hold for release until an inbound IFR aircraft had arrived at KMGY. At 2:04, Flight 1526 advised ATC they were number one for departure from KMGY. Five minutes later, the flight was given its departure release with a climb to 3,000 feet and direct to the Appleton VOR. The flight departed Runway 20 and, at about 2:14, checked in with ATC.

Based on what they heard on the CVR, investigators concluded that the first officer was doing the flying and the captain was the monitoring pilot. The NTSB said this was contrary to what normally was done at Execuflight when revenue passengers were onboard; the captain should have been flying.

At 2:16, ATC cleared the flight to 17,000 feet, and two minutes later cleared the flight to the Akron airport.

At about 2:27, the first offer asked the captain to brief the approach. Execuflight's standard operating procedures required that the pilot who was doing the flying should conduct the approach briefing. Based on what the investigators heard on the CVR, they concluded that the briefing was unstructured, inconsistent and incomplete, and the pilots didn't complete the approach checklist. The first officer and captain each could be heard mentioning some checklist items. During the next few minutes, the pilots discussed the localizer approach to Runway 25 at KAKR, approach minimums, how high the bases of the overcast were in relation to the ground, and the missed approach procedure. The flight was handed off from Cleveland Center to Akron Approach.

At about 2:37, the pilots discussed an approach minimum of 1,520 feet MSL, making the height above the ground 501 feet. At about 2:38, the CVR picked up the crew listening to the KAKR automated weather station's broadcast. The weather included a 600-foot AGL broken ceiling, visibility of 1½ miles in mist and wind of 240 degrees at 8 knots.

At 2:46, ATC told the flight to slow to 170 knots and descend to 3,000 feet. ATC advised the Hawker pilots there was a slower airplane on the approach.

At about 2:48, the first officer said something about drag. At 2:49, when the flight was about four miles from the final approach fix, the approach controller radioed that the training flight had canceled IFR and the Hawker was cleared for the localizer approach. The flight acknowledged and reported being established on the localizer. About that time, the CVR recorded sounds similar to the landing gear being extended. Investigators suggested that the first officer would have lowered the flaps to 25 degrees at this time. The airplane could have descended to 2,300 feet MSL at this time, but remained at 3,000 feet.

Descents to the minimum descent altitude (MDA) in the Hawker 700A normally are conducted via the vertical speed function of the autopilot and flight director. According to the Execuflight Chief Pilot, they targeted about 1,000 feet per minute on the descent from the final approach fix (FAF) to the MDA.

Someone from the training flight radioed on the airport advisory frequency that they "broke out at minimums" and were clear of the runway. The CVR shows that one of the Hawker pilots acknowledged the report.

At about 2:48, the captain told the first officer they were flying nine degrees nose up, and expressed concern about decreasing speed. The airplane had slowed to about 125 knots. The proper approach speed with flaps at 25 degrees would have been 144 knots. At 2:50, ATC cleared the flight to change to the airport advisory frequency and cancel IFR either on the ground or in the air. Then, the captain expressed concern to the first officer about stalling the airplane. According to the CVR, he said, "Look, you're going one twenty (knots). You can't keep decreasing your speed." The first officer responded, "No, one tw---how do you get one twenty?" The captain replied, "One twenty five," and the first officer jumped in with what sounded like, "V-ref plus fifteen." The captain said, "...if you keep decreasing your speed...we gonna stall!."

At this point, only fragments of what was being said could be deciphered from the CVR, but it appeared the first officer was doing prelanding checks and, at 2:51, called for full flaps. That would have been 45 degrees. The use of full flaps isn't permitted by Execuflight's profile governing nonprecision approaches in the HS-125-700A until after descending to the minimum descent altitude (MDA) and landing is assured. The captain didn't question the use of 45 degrees flaps so far out on the approach, according to what could be heard on the CVR.

At 2:51:56, the captain said, "...on localizer. You're diving. You're diving. Don't dive. Two thousand feet per minute, buddy." The first officer replied, "Yeah," and the captain repeated "Don't go two thousand feet per minute." Five seconds later, the captain repeated, "Don't go [descend] two thousand feet per minute."

The Safety Board said the captain could have, and should have, taken control of the airplane and initiated a missed approach. The Safety Board also faulted him for not calling out the MDA. At 2:52:27, as the airplane descended below the MDA, the captain told the first officer, "Okay, level off, guy." By this time, the airplane was flying at only about 114 knots, with 45 degrees of flaps creating a lot of drag. As soon as the first officer reacted and pulled back, the stall warning stick shaker activated. Several seconds later, the CVR picked up the first sounds of impact.

Multiple witnesses observed the airplane descending in a left banked turn as it impacted the apartment building. The physical evidence collected at the accident site indicated that the airplane crashed with the landing gear down and the flaps configured to 45 degrees.

Investigators interviewed other Execuflight pilots who stated that a nonprecision approach was only supposed to be flown from the final approach fix with the flaps at 25 and gear extended. They said flaps at 45 degrees should only be used when the landing is "assured." The NTSB said someone needs to clearly define just what "landing assured" means.

A Hawker instructor told investigators that he didn't know of any situation in the training program where a pilot was taught to fly with flaps at 45 degrees in level flight. He stated he would never do that, wasn't even sure what the power setting would be, and that it would be "nuts" to do that. The truth is, as this accident shows, it's not merely "nuts"---it can be deadly.

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.