The pilot's decision to continue a high-speed steep visual approach to London-area Blackbushe Airport in the UK resulted in the July 4, 2015 fatal crash of an Embraer Phenom 300 operated by the Bin Laden family-owned Salem Aviation, the UK Air Accidents Investigation Branch (AAIB) determined in its December 8 final report. Mitigating circumstances included excessive stimulation from aural warnings distracting the single pilot and a locked gate that delayed fire and rescue crews. All four aboard—the pilot and three passengers—were killed in the accident.
The Jordanian pilot held a Saudi Arabian ATP certificate and had flown into Blackbushe Airport several times. According to the AAIB report, there was no evidence of any mechanical problem. VMC) prevailed and the predicted aircraft performance at a calculated 105 kias touchdown speed was a landing distance of 2,400 feet and ground roll of 1,302 feet on Runway 25, which measures 4,380 feet long.
After the handoff from Farnborough Approach, Blackbushe Airport Flight Information told the pilot about a microlight in the landing pattern. The pilot said he would extend downwind to let the microlight land first. He then crossed the microlight’s path, generating the first of several TCAS warnings—a Cessna on a cross-country flight triggered another. The Phenom accelerated and climbed to resolve the traffic alerts and lined up with the runway well above the normal glideslope with landing flaps extended. The pilot initiated a 3,000-fpm descent and selected speed brakes, but they are inhibited with flaps deployed and did not activate.
With an airspeed of 153 knots and pitch attitude of 13 degrees nose down at 1,125 feet agl, the Taws “pull up” excessive-descent-rate warning triggered. At 675 feet agl the pilot again selected speed brakes and again they did not activate. Descending through 500 feet agl the Phenom’s airspeed was 156 knots and the rate of descent was 2,500 fpm. At 200 feet agl and 155 knots, the rate of descent was 2,000 fpm. The advisory controller called the runway clear for landing; the pilot did not respond.
The Phenom crossed the runway threshold on the glideslope but 43 knots above target speed, touching down 2,330 feet beyond the threshold and braking heavily. The aircraft left the paved surface at a groundspeed of 83 knots, hitting an earth embankment, and then bounced into cars parked in a lot beyond it, shedding a wing and catching fire.
Investigators concluded that the occupants survived the crash but were unable to open the exit quickly enough and died in the fire. The Blackbushe Airport fire and rescue squad was delayed by a locked gate and had to wait for it to be unlocked before proceeding to the accident site to extinguish the fire.
Although the aircraft regularly operated to Blackbushe, most of the destinations to which Salem’s Phenom 300 flew were large international airports in Europe and the Middle East. Analysis of FDR data showed that visual approaches were rare and seldom flown at airports other than Blackbushe.
Investigators reviewed data from 46 flights of the accident aircraft and 55 flights of the company’s other Phenom 300, focusing on approaches. The pilot of the accident flight flew 20 of the examined flights. Evidence showed that the Phenoms had experienced several steep, high-speed “slam dunk” final approaches.
Accident data showed that the pilot heard no fewer than 36 aural prompts, transmissions or warnings in the cockpit in the last two minutes and 19 seconds of flight. The AAIB report listed the high workload for the single pilot and particularly audio overload and its invoked mental stressors as reasons why he fixated on continuing the approach toward the short runway. The fact that he had successfully performed such approaches before might have contributed to his mindset, the AAIB suggested. In addition, flight department manuals only mandated that final approaches be stabilized on glideslope by 200 feet agl.
The accident pilot was operating the Phenom 300 single-pilot, for which the company held certification. Now, the company’s Phenom 300s are crewed by two pilots, and final approaches must be stabilized on normal glideslope by 500 feet agl or the crew must initiate a go-around. Single-pilot operations are allowed only on short flights in low-workload environments. The flight department also adopted a Flight Operations Quality Assurance (FOQA) program and enhanced recurrent training requirements with a focus on short-runway operations. Its approach brief now emphasizes go-arounds in VMC. Mandatory pilot and team meetings have also been introduced.
Blackbushe Airport’s operator now has crash gate keys aboard each rescue and fire vehicle, and its operational and training documentation shows the locked gates and how to open them.