Crash of an Embraer EMB-505 Phenom 300 in Houston

Date & Time: Jul 26, 2016 at 1510 LT
Type of aircraft:
Operator:
Registration:
N362FX
Survivors:
Yes
Schedule:
Scottsdale - Houston
MSN:
500-00239
YOM:
2014
Flight number:
LXJ362
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9246
Captain / Total hours on type:
1358.00
Copilot / Total flying hours:
11362
Copilot / Total hours on type:
962
Aircraft flight hours:
1880
Circumstances:
The pilot executed an instrument approach and landing in heavy rain. The airplane touched down about 21 knots above the applicable landing reference speed, which was consistent with an unstabilized approach. The airplane touched down near the displaced runway threshold about 128 kts, and both wing ground spoilers automatically deployed. The pilot reported that the airplane touched down “solidly,” and he started braking promptly, but the airplane did not slow down. The main wheels initially spun up; however, both wheel speeds subsequently decayed consistent with hydroplaning in the heavy rain conditions. When the wheel speeds did not recover, the brake control unit advised the flight crew of an anti-skid failure; the pilot recalled an anti-skid CAS message displayed at some point during the landing. The pilot subsequently activated the emergency brake system and the wheel speeds decayed. The airplane ultimately overran the departure end of the runway about 60 kts, crossed an airport perimeter road, and encountered a small creek before coming to rest. The wings had separated from, and were located immediately adjacent to, the fuselage. The pilot reported light to moderate rain began on final approach. Weather data and surveillance images indicated that heavy rain and limited visibility prevailed at the airport during the landing. Thunderstorms were active in the vicinity and the rainfall rate at the time of the accident landing was between 4.2 and 6.0 inches per hour. About 4 minutes before the accident, a surface observation recorded the visibility as 3 miles. However, 3 minutes later, the observed visibility had decreased to 3/8 mile. A review of the available information indicated that the tower controller advised the pilot of changing wind conditions and of better weather west of the airport but did not update the pilot regarding visibility along the final approach course or precipitation at the airport. The pilot stated that the rain started 2 to 3 minutes before he landed and commented that it was not the heaviest rain that he had ever landed in. The pilot was using the multifunction display and a tablet for weather radar, which showed green and yellow returns indicating light to moderate rain during the approach. He chose not to turn on the airplane’s onboard weather radar because the other two sources were not indicating severe weather. The runway exhibited skid marks beginning about 1,500 ft from the departure end and each main tire had one patch of reverted rubber wear consistent with reverted rubber hydroplaning. The main landing gear remained extended and both tires remained pressurized. The tire pressures corresponded to a minimum dynamic hydroplaning speed of about 115 kts. The airplane flight manual noted that, in the case of an antiskid failure, the main brakes are to be applied progressively and brake pressure is to be modulated as required. The emergency brake is to be used in the event of a brake failure; however, the pilot activated the emergency brake when the main brakes still functioned; although, without anti-skid protection.
Probable cause:
The airplane’s hydroplaning during the landing roll, which resulted in a runway excursion. Contributing to the accident was the pilot’s continuation of an unstabilized approach, his decision to land in heavy rain conditions, and his improper use of the main and emergency brake systems. Also contributing was the air traffic controller’s failure to disseminate current airport weather conditions to the flight crew in a timely manner.
Final Report:

Crash of a Cessna 208B Grand Caravan in Akobo

Date & Time: Jun 3, 2016 at 1000 LT
Type of aircraft:
Operator:
Registration:
5Y-JLL
Flight Phase:
Survivors:
Yes
Schedule:
Akobo - Juba
MSN:
208B-2158
YOM:
2009
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 3 June 2016, a Cessna 208B of registration 5Y-JLL and serial number 2158 was conducting a charter passenger flight from Akobo Airstrip to Juba with 4 passengers and one flight crew member on board. According to the operator, during takeoff from Akobo Airstrip at approximately 10 a.m. Local Time, the pilot executed a premature takeoff due to animal incursion on the runway. The airplane's right main landing gear clipped the Airstrip perimeter fence and the aircraft crash-landed onto grass-thatched houses and trees near the end of the runway. Damage was substantial with no reported injuries. The runway was reported to have been wet at the time of occurrence.
Final Report:

Crash of a Britten-Norman BN-2T Islander in Kiunga: 12 killed

Date & Time: Apr 13, 2016 at 1420 LT
Type of aircraft:
Operator:
Registration:
P2-SBC
Survivors:
No
Schedule:
Oksapmin – Kiunga
MSN:
3010
YOM:
1983
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
4705
Captain / Total hours on type:
254.00
Aircraft flight hours:
2407
Aircraft flight cycles:
2886
Circumstances:
On the afternoon of 13 April 2016, a Pilatus Britten Norman Turbine Islander (BN-2T) aircraft, registered P2-SBC, operated by Sunbird Aviation Ltd, departed from Tekin, West Sepik Province for Kiunga, Western Province, as a charter flight under the visual flight rules. On board were the pilot-in-command (PIC) and 11 passengers (eight adults and three children). The aircraft was also carrying vegetables. The pilot reported departing Oksapmin at 13:56. The pilot had flight planned, Kiunga to Oksapmin to Kiunga. However, the evidence revealed that without advising Air Traffic Services, the pilot flew from Oksapmin to Tekin. On departure from Tekin the pilot transmitted departure details to ATS, stating departure from Oksapmin. The recorded High Frequency radio transmissions were significantly affected by static and hash. The weather at Kiunga was reported to be fine. As the aircraft entered the Kiunga circuit area, the pilot cancelled SARWATCH with Air Traffic Services (ATS). The pilot did not report an emergency to indicate a safety concern. Witnesses reported that during its final approach, the aircraft suddenly pitched up almost to the vertical, the right wing dropped, and the aircraft rolled inverted and rapidly “fell to the ground”. It impacted the terrain about 1,200 metres west of the threshold of runway 07. The impact was vertical, with almost no forward motion. The aircraft was destroyed, and all occupants were fatally injured.
Probable cause:
The aircraft’s centre of gravity was significantly aft of the aft limit. When landing flap was set, full nose-down elevator and elevator trim was likely to have had no effect in lowering the nose of the aircraft. Unless the flaps had been retracted immediately, the nose-up pitch may also have resulted in tail plane stall, exacerbating the pitch up. The wings stalled, followed immediately by the right wing dropping. Recovery from the stall at such a low height was not considered possible.
Other factors:
Other factors is used for safety deficiencies or concerns that are identified during the course of the investigation, that while not causal to the accident, nevertheless should be addressed with the
aim of accident and serious incident prevention, and the safety of the travelling public.
a) Following the reweighing of SBC, the operator did not make adjustments to account for the shift of the moment arm as a result of the reweighing. Specifically, a reduction of allowable maximum weight in the baggage compartment.
b) The pilot, although signing the flight manifest on previous flights attesting that the aircraft was loaded within c of g limits, had not computed the c of g. No documentation was available to confirm that the pilot had computed the c of g for the accident flight, or any recent flights.
c) All of the High Frequency radio transmissions between Air Traffic Services and SBC were significantly affected by static interference and a lot of hash, making reception difficult, and many transmissions unclear and unreadable. This is a safety concern to be addressed to ensure that vital operational radio transmissions are not missed for the safety of aircraft operations, and the travelling public.
Final Report:

Crash of a Cessna 208B Grand Caravan near Tayoltita: 3 killed

Date & Time: Apr 1, 2016 at 0917 LT
Type of aircraft:
Operator:
Registration:
XA-ULU
Flight Phase:
Survivors:
Yes
Schedule:
Tayoltita - Durango
MSN:
208B-2104
YOM:
2009
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7443
Aircraft flight hours:
4027
Aircraft flight cycles:
3479
Circumstances:
The single engine airplane departed Tayoltita Airfield around 0900LT on a charter flight to Durango, carrying nine passengers and one pilot. Twelve minutes into the flight, the pilot encountered engine problems and declared an emergency. Unable to maintain a safe altitude, he attempted an emergency landing when the aircraft crashed in the bed of the Piaxtla River. The wreckage was found about 16 km northeast of Tayoltita Airfield (N 24° 11' 2.65" W 105° 47' 12.57''). The aircraft was destroyed by impact forces and there was no fire. Three passengers were killed and seven other occupants were injured.
Probable cause:
The accident was the consequence of a loss of control following the failure of a turbine compressor disc blade. It was reported that unauthorized repairs had been made on the engine without the approval of the engine manufacturer.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Le Havre-aux-Maisons: 7 killed

Date & Time: Mar 29, 2016 at 1230 LT
Type of aircraft:
Operator:
Registration:
N246W
Survivors:
No
Schedule:
Montreal - Le Havre-aux-Maisons
MSN:
1552
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
2500
Captain / Total hours on type:
125.00
Aircraft flight hours:
11758
Circumstances:
The twin engine aircraft left Montreal-Saint-Hubert Airport at 0930LT for a two hours flight to Le Havre-aux-Maisons, on Magdalen Islands. Upon arrival, weather conditions were marginal with low ceiling, visibility up to two miles, rain and wind gusting to 30 knots. During the final approach to Runway 07, when the aircraft was 1.4 nautical miles west-southwest of the airport, it deviated south of the approach path. At approximately 1230 Atlantic Daylight Time, aircraft control was lost, resulting in the aircraft striking the ground in a near-level attitude. The aircraft was destroyed and all seven occupants were killed, among them Jean Lapierre, political commentator and former Liberal federal cabinet minister of Transport. All passengers were flying to Magdalen Islands to the funeral of Lapierre's father, who died last Friday. The captain, Pascal Gosselin, was the founder and owner of Aéro Teknic.
Crew:
Pascal Gosselin, pilot.
Passengers:
Fabrice Labourel, acting as a copilot,
Jean Lapierre,
Nicole Beaulieu, Jean Lapierre's wife,
Martine Lapierre, Jean Lapierre's sister,
Marc Lapierre, Jean Lapierre's brother,
Louis Lapierre, Jean Lapierre's brother.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot’s inability to effectively manage the aircraft’s energy condition led to an unstable approach.
2. The pilot “got behind” the aircraft by allowing events to control his actions, and cognitive biases led him to continue the unstable approach.
3. A loss of control occurred when the pilot rapidly added full power at low airspeed while at low altitude, which caused a power-induced upset and resulted in the aircraft rolling sharply to the right and descending rapidly.
4. It is likely that the pilot was not prepared for the resulting power-induced upset and, although he managed to level the wings, the aircraft was too low to recover before striking the ground.
5. The pilot’s high workload and reduced time available resulted in a task-saturated condition, which decreased his situational awareness and impaired his decision making.
6. It is unlikely that the pilot’s flight skills and procedures were sufficiently practised to ensure his proficiency as the pilot-in-command for single-pilot operation on the MU2B for the conditions experienced during the occurrence flight.

Findings as to risk:
1. If the weight of an aircraft exceeds the certified maximum take-off weight, there is a risk of aircraft performance being degraded, which may jeopardize the safety of the flight.
2. If pilots engage in non-essential communication during critical phases of flight, there is an increased risk that they will be distracted, which reduces the time available to complete cockpit activities and increases their workload.
3. If flight, cockpit, or image/video data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
4. If pilots do not recognize that changing circumstances require a new plan, then plan continuation bias may lead them to continue with their original plan even though it may not be safe to do so.
5. If pilots do not apply stable-approach criteria, there is a risk that they will continue an unstable approach to a landing, which can lead to an approach-and-landing accident.
6. If pilots are not prepared to conduct a go-around on every approach, they risk not responding appropriately to situations that require one.
7. If a flight plan does not contain search-and-rescue supplementary information, and if that information is not transmitted or readily available, there is a risk that first responders will not have the information they need to respond adequately.

Other findings:
1. Transport Canada does not monitor or track the number of days foreign-registered aircraft are in Canada during a given 12-month period.
2. Turbulence and icing were not considered factors in this occurrence.
3. Transport Canada considers that the discretionary installation of an angle-of-attack system on normal-category, type-certificated, Canadian-registered aircraft is a major modification that requires a supplemental type certificate approval.
4. Although the aircraft was not in compliance with Airworthiness Directive 2006-17-05 at the time of the occurrence, there was no indication that it was operating outside of the directive’s specifications.
5. Although not required by regulation, the installation and use of a lightweight flight recording system during the occurrence flight, as well as the successful retrieval of its data during the investigation, permitted a greater understanding of this accident.
Final Report:

Crash of a Beechcraft 1900D in Karachi

Date & Time: Mar 18, 2016 at 0820 LT
Type of aircraft:
Operator:
Registration:
AP-BII
Flight Phase:
Survivors:
Yes
Schedule:
Karachi – Sui
MSN:
UE-45
YOM:
1993
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2885
Captain / Total hours on type:
717.00
Copilot / Total flying hours:
3614
Copilot / Total hours on type:
245
Aircraft flight hours:
19574
Aircraft flight cycles:
30623
Circumstances:
The Aircraft Sales and Services (Private) Limited (ASSL) aircraft Beechcraft-1900D Registration No. AP-BII was scheduled for a chartered flight on 18th March, 2016 from Karachi to Sui. Just after takeoff from runway 25L at 0820 hrs local time, the crew observed power loss of right engine and made a gear up landing on the remaining runway on the right side of centreline. After touchdown, the aircraft went off the runway towards right side and then came back on the runway before coming to a final stop 1,050 feet short from the end of runway. The Captain and one passenger received serious injuries due to hard impact of the aircraft with ground. All other passengers and technician remained unhurt.
Probable cause:
The investigation therefore, concludes that:
- Some internal malfunction of the Propeller Governor Part No. 8210-410 Serial No. 2490719 was the cause of experienced uncommanded auto feather. However, exact cause of the occurrence could not be determined.
- Continuing take off below V1 speed (104kts) after encountering engine malfunction and after takeoff raising flaps below recommended height (400ft AGL) lead to decrease in lift and unsustainability of flight.
Final Report:

Crash of a Cessna 208B Grand Caravan near Anaktuvuk Pass

Date & Time: Jan 2, 2016 at 1205 LT
Type of aircraft:
Operator:
Registration:
N540ME
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Fairbanks - Anaktuvuk Pass
MSN:
208B-0540
YOM:
1996
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8854
Captain / Total hours on type:
4142.00
Aircraft flight hours:
19555
Circumstances:
The airline transport pilot was conducting a scheduled passenger flight in an area of remote, snow-covered, mountainous terrain with seven passengers on board. The pilot reported that, after receiving a weather briefing, he chose to conduct the flight under visual flight rules (VFR). While en route about 10,000 ft mean sea level (msl), the visibility began "getting fuzzy." The pilot then descended the airplane to 2,500 ft msl (500 ft above ground level) to fly along a river. When the airplane was about 10 miles southwest of the airport, he climbed the airplane to about 3,000 ft msl in order to conduct a straight-in approach to the runway. He added that the visibility was again a little "fuzzy" due to snow and clouds, and that he never saw the airport. The pilot also noted that the flat light conditions limited his ability to determine his distance from the surrounding mountainous, snow-covered terrain. Shortly after climbing to 3,000 ft msl, the airplane collided with the rising terrain about 6 miles southwest of the airport. Another pilot, who had just departed from the airport, confirmed that flat light and low-visibility conditions existed in the area at the time of the accident. Further, camera images of the weather conditions recorded at the airport showed that, although conditions were marginal VFR at the surface at the time of the accident, there was mountain obscuration and reduced visibility due to light snow and clouds along the accident flight path and that the worst conditions were located along and near the higher terrain. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. It is likely that that the pilot encountered flat light and low-visibility conditions as he neared the airport at 3,000 ft msl while operating under VFR and that he did not see the rising, snow-covered mountainous terrain and subsequently failed to maintain clearance from it.
Probable cause:
The pilot's continued flight into deteriorating, flat light weather conditions, which resulted in impact with mountainous, snow-covered terrain.
Final Report:

Crash of a Beechcraft BeechJet 400A in Telluride

Date & Time: Dec 23, 2015 at 1415 LT
Type of aircraft:
Operator:
Registration:
XA-MEX
Survivors:
Yes
Schedule:
Monterrey – El Paso – Telluride
MSN:
RK-396
YOM:
2004
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7113
Captain / Total hours on type:
1919.00
Copilot / Total flying hours:
8238
Copilot / Total hours on type:
1412
Aircraft flight hours:
5744
Circumstances:
The pilots were conducting an international chartered flight in the small, twin-engine jet with five passengers onboard. Since the weather at the destination was marginal, the flight crew had discussed an alternate airport in case weather conditions required a missed approach at their destination. As the airplane neared the non-towered destination airport, the flight crew received updated weather information, which indicated that conditions had improved. Upon contacting the center controller, the crew was asked if they had the weather and NOTAMS for the destination airport. The crew reported that they received the current weather information, but did not state if they had NOTAM information. The controller responded by giving the flight a heading for the descent and sequence into the airport. The controller did not provide NOTAM information to the pilots. About 2 minutes later, airport personnel entered a NOTAM via computer closing the runway, effective immediately, for snow removal. Although the NOTAM was electronically routed to the controller, the controller's system was not designed to automatically alert the controller of a new NOTAM; the controller needed to select a display screen on the equipment that contained the information. At the time of the accident, the controller's workload was considered heavy. About 8 minutes after the runway closure NOTAM was issued, the controller cleared the airplane for the approach. The flight crew then canceled their instrument flight plan with the airport in sight, but did not subsequently transmit on or monitor the airport's common traffic advisory frequency, which was reportedly being monitored by airport personnel and the snow removal equipment operator. The airplane landed on the runway and collided with a snow removal vehicle about halfway down the runway. The flight crew reported they did not see the snow removal equipment. The accident scenario is consistent with the controllers not recognizing new NOTAM information in a timely manner due to equipment limitations, and the pilots not transmitting or monitoring the common traffic advisory frequency. Additionally, the accident identifies a potential problem for flight crews when information critical to inflight decision-making changes while en route, and problems when controller workload interferes with information monitoring and dissemination.
Probable cause:
The limitations of the air traffic control equipment that prevented the controller's timely recognition of NOTAM information that was effective immediately and resulted in the issuance of an approach clearance to a closed runway. Also causal was the pilots' omission to monitor and transmit their intentions on the airport common frequency. Contributing to the accident was the controller's heavy workload and the limitations of the NOTAM system to distribute information in a timely manner.
Final Report:

Crash of a Cessna 402B in Acandí: 2 killed

Date & Time: Nov 17, 2015 at 1054 LT
Type of aircraft:
Operator:
Registration:
HK-4981G
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Acandí – Medellín
MSN:
402B-1042
YOM:
1976
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Acandí-Alcides Fernandez Airport, while in initial climb, the twin engine aircraft stalled and crashed in a house located in the district of Miramar, near the airport. The pilot and a passenger were killed and eight other occupants were injured. There were no victims on the ground and the aircraft was destroyed.
Probable cause:
Stall during initial climb due to the combination of the following factors:
- The total weight of the aircraft was above the MTOW,
- The CofG was outside the enveloppe,
- Poor flight planning.

Crash of a BAe 125-700A in Akron: 9 killed

Date & Time: Nov 10, 2015 at 1453 LT
Type of aircraft:
Operator:
Registration:
N237WR
Survivors:
No
Site:
Schedule:
Dayton – Akron
MSN:
257072
YOM:
1979
Flight number:
EFT1526
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
6170
Captain / Total hours on type:
1020.00
Copilot / Total flying hours:
4382
Copilot / Total hours on type:
482
Aircraft flight hours:
14948
Aircraft flight cycles:
11075
Circumstances:
The aircraft departed controlled flight while on a non precision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and post crash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Dayton-Wright Brothers Airport, Dayton, Ohio, about 1413 and was destined for AKR. Contrary to Execuflight’s informal practice of the captain acting as pilot flying on flights carrying revenue passengers, the first officer was the pilot flying, and the captain was the pilot monitoring. While en route, the flight crew began preparing for the approach into AKR. Although company standard operating procedures (SOPs) specified that the pilot flying was to brief the approach, the captain agreed to the first officer’s request that the captain brief the approach. The ensuing approach briefing was unstructured, inconsistent, and incomplete, and the approach checklist was not completed. As a result, the captain and first officer did not have a shared understanding of how the approach was to be conducted. As the airplane neared AKR, the approach controller instructed the flight to reduce speed because it was following a slower airplane on the approach. To reduce speed, the first officer began configuring the airplane for landing, lowering the landing gear and likely extending the flaps to 25° (the airplane was not equipped with a flight data recorder, nor was it required to be). When the flight was about 4 nautical miles from the final approach fix (FAF), the approach controller cleared the flight for the localizer 25 approach and instructed the flight to maintain 3,000 ft mean sea level (msl) until established on the localizer. The airplane was already established on the localizer when the approach clearance was issued and could have descended to the FAF minimum crossing altitude of 2,300 ft msl. However, the first officer did not initiate a descent, the captain failed to notice, and the airplane remained level at 3,000 ft msl. As the first officer continued to slow the airplane from about 150 to 125 knots, the captain made several comments about the decaying speed, which was well below the proper approach speed with 25° flaps of 144 knots. The first officer’s speed reduction placed the airplane in danger of an aerodynamic stall if the speed continued to decay, but the first officer apparently did not realize it. The first officer’s lack of awareness and his difficulty flying the airplane to standards should have prompted the captain to take control of the airplane or call for a missed approach, but he did not do so. Before the airplane reached the FAF, the first officer requested 45° flaps and reduced power, and the airplane began to descend. The first officer’s use of flaps 45° was contrary to Execuflight’s Hawker 700A non precision approach profile, which required the airplane to be flown at flaps 25° until after descending to the minimum descent altitude (MDA) and landing was assured; however, the captain did not question the first officer’s decision to conduct the approach with flaps 45°. The airplane crossed the FAF at an altitude of about 2,700 ft msl, which was 400 ft higher than the published minimum crossing altitude of 2,300 ft msl. Because the airplane was high on the approach, it was out of position to use a normal descent rate of 1,000 feet per minute (fpm) to the MDA. The airplane’s rate of descent quickly increased to 2,000 fpm, likely due to the first officer attempting to salvage the approach by increasing the rate of descent, exacerbated by the increased drag resulting from the improper flaps 45° configuration. The captain instructed the first officer not to descend so rapidly but did not attempt to take control of the airplane even though he was responsible for safety of the flight. As the airplane continued to descend on the approach, the captain did not make the required callouts regarding approaching and reaching the MDA, and the first officer did not arrest the descent at the MDA. When the airplane reached the MDA, which was about 500 ft above the touchdown zone elevation, the point at which Execuflight’s procedures dictated that the approach must be stabilized, the airspeed was 11 knots below the minimum required airspeed of 124 knots, and the airplane was improperly configured with 45° flaps. The captain should have determined that the approach was unstabilized and initiated a missed approach, but he did not do so. About 14 seconds after the airplane descended below the MDA, the captain instructed the first officer to level off. As a result of the increased drag due to the improper flaps 45° configuration and the low airspeed, the airplane entered a stalled condition when the first officer attempted to arrest the descent. About 7 seconds after the captain’s instruction to level off, the cockpit voice recorder (CVR) recorded the first sounds of impact.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this 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 minimum descent altitude 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 Federal Aviation Administration’s insufficient oversight of the company’s training program and flight operations.
Final Report: