The NTSB, finding significant deficiencies with the crew’s management of the approach that ended in a Hawker 700A crash on November 10 last year, is calling on the FAA to mandate flight data monitoring programs for Part 135 operators. The Board is also asking for a requirement to install flight data recorders that can support those programs, safety management systems (SMSs), improved approach training and better processes to identify Part 135 operators that do not comply with standard operating procedures.
Those recommendations were among 13 the Board made as a result of its investigation into the crash that occurred while the Hawker, N237WR, was on a non-precision approach to Runway 25 at Akron-Fulton International Airport (AKR). All nine people on board were killed.
The NTSB cited as a probable cause “the flight crew’s mismanagement of the approach and multiple deviations from the company standard operating procedures, which placed the airplane in an unsafe situation and led to an unstabilized approach.” It further cited the operator’s “casual attitude toward compliance with standards,” inadequate training and operational oversight, lack of a formal safety program and insufficient FAA oversight. The Safety Board believes that flight data monitoring, as well as SMS programs, might have uncovered the deficiencies that contributed to the crash.
According to NTSB chairman Christopher Hart, travelers on charter flights “implicitly trust that FAA standards, the charter company’s standard operating procedures and the professionalism of the pilots will protect them from harm. The protections built into the system were not applied, and they should have been.” The recommendations, he added, are designed to help operators make sure their flight operations are safe and in compliance with regulations, as well as help the FAA identify operators with a systemic disregard for the regulations.
“These companies must either improve their practices or close their doors,” the chairman said. “All companies have a responsibility to follow the regulations and to actively manage safety in all facets of their operations.”
The accident flight, Execuflight Flight 1526, had departed Dayton-Wright Brothers Airport in Dayton, Ohio, at 2:12 p.m. local time on a flight to AKR. While Execuflight had an informal practice of the captain acting as pilot on revenue-passenger carrying flights, the first officer was the pilot flying on this particular flight; the captain took the role of pilot monitoring.
The company’s standard operating procedures specified that the pilot flying brief the approach, but in this case the captain—at the request of the first officer—agreed to brief the approach. “The ensuing approach briefing was unstructured, inconsistent and incomplete, and the approach checklist was not completed,” the NTSB said. “As a result, the captain and the first officer did not have a shared understanding of how the approach was to be conducted.”
Accident Landing Sequence
As the aircraft approached AKR, the controller instructed the pilots to reduce speed because the Hawker was following a slower airplane. To comply, the first officer began configuring the airplane for landing, the NTSB believes, by lowering the landing gear and possibly extending the flaps to 25 degrees. Since the aircraft was not equipped with a flight data recorder, this is an estimate on the part of the Safety Board. About 4 nm from the final approach fix, the controller cleared the Hawker for the localizer 25 approach and instructed the pilots to maintain 3,000 feet msl until established on the localizer. But the airplane was already established on the localizer when that clearance was given, the NTSB said, adding that the aircraft could have descended to the final approach fix minimum crossing altitude of 2,300 feet msl. But the aircraft maintained 3,000 feet.
The airplane continued to slow from 150 knots to 125 knots, well below the proper approach speed of 144 knots with flaps at 25 degrees. The captain made several comments about the dwindling speed, the NTSB investigation revealed. “The first officer’s speed reduction placed the airplane in danger of an aerodynamic stall…but the first officer apparently did not realize it,” the Safety Board said. “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 final approach fix, the first officer requested 45-degree flaps and reduced power, and the airplane began to descend. The use of the 45-degree flaps was not in line with Execuflight’s Hawker 700A nonprecision approach profile, which calls for 25 degrees until after reaching the minimum descent altitude (MDA) and landing is assured.
The captain, however, did not question the first officer’s actions. The airplane crossed the final approach fix at 2,700 feet msl, 400 feet higher than the minimum crossing altitude. Since the aircraft was high on the approach, the rate of descent steepened to 2,000 fpm, twice the normal rate. The NTSB attributed this “to the first officer [likely] attempting to salvage the approach by increasing the rate of descent, exacerbated by the greater drag resulting from the improper flaps 45 degrees configuration.”
While the captain told the first officer not to descend so rapidly, he did not take control of the airplane. Nor did he make required callouts regarding approaching and reaching MDA. Execuflight procedures state that at MDA the approach must be stabilized. But when the Hawker reached MDA, about 500 feet above touchdown elevation, the aircraft was 11 knots below the minimum required airspeed of 124 knots and with the flaps improperly configured at 45 degrees. “The captain should have determined that the approach was unstabilized and initiated a missed approach, but he did not do so,” the NTSB said. Fourteen seconds past MDA, the captain called for the first officer to level off. But the airplane stalled and crashed into a four-unit apartment building at 2:53 p.m. The captain, first officer and all seven passengers died; no one on the ground was injured.
NTSB Findings and Recommendations
In its investigation, NTSB cited an “unstructured, inconsistent and incomplete” briefing for a nonprecision approach and further contended that the first officer’s action “placed the airplane in danger” and while the captain recognized the situation, he never took over control. “The captain’s failure to enforce adherence to standard operating procedures and his mismanagement of the approach placed the airplane in an unsafe situation that ultimately resulted in the loss of control,” the NTSB found.
The investigation further revealed that both the captain and first officer had been fired by their previous employers—the captain for failure to show up for recurrent training and the first officer for performance deficiencies.
Further, the weight-and-balance measurements for the accident flight were wrong. In addition, the NTSB found shortcomings in the crew resource management training, inadequate training for continuous descent approaches and deficient maintenance records on the part of the operator, Execuflight.
Execuflight did not make anyone available to AIN for comment.
The NTSB said the accident points to a number of safety issues, among them the lack of flight data monitoring programs. These programs help identify operational deficiencies, such as noncompliance with standard operating procedures, the Safety Board said, adding that it “has investigated many other Part 135 accidents in which the operator lacked the means to monitor routine operations.”
The Safety Board also pointed to a need for SMS, which reinforces a positive safety culture and can help identify deviations from standard operating procedures. “This accident is one of many Part 135 accidents and incidents in which the NTSB has determined that inadequate operational safety oversight played a role.”
Further, the Safety Board identified a need for a Hawker 700- and 800-series nonprecision approach procedure that meets stabilized approach criteria and defines “landing assured.” The NTSB pointed to a lack of definition of landing assured and the varying definitions provided by Hawker simulator instructors, some of which conflict with regulations regarding descending below the MDA. The NTSB also sees a need for training on the continuous descent approach final technique and improved FAA surveillance of Part 135 operations.
These findings led the numerous recommendations to the FAA, training centers and Textron Aviation, covering safety programs, training and oversight.