BRITISH AEROSPACE HS 125 700AExecuflight
Akron, OH, USA · 2015-11-10·N237WR
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-16/03. On November 10, 2015, about 1453 eastern standard time (EST), Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), N237WR, departed controlled flight while on a nonprecision 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 postcrash 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 (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed from Dayton-Wright Brothers Airport (MGY), Dayton, Ohio, about 1413 and was destined for AKR.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationThe 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.
Occurrence sequence
2 stepsNTSB coding · CICTT taxonomy- 1 · Approach-IFR final approachAerodynamic stall/spindefining event
- 2 · Approach-IFR final approachCollision with terr/obj (non-CFIT)
Findings
8 causal · 3 contributing- CAUSEPersonnel issues › Action/decision › Action › Incorrect action performance — Flight crew
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters › Descent/approach/glide path — Not attained/maintained
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters › Angle of attack — Capability exceeded
- CAUSEOrganizational issues › Development › Selection/certification/testing › Personnel selection/training — Operator
- CAUSEOrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of reg compliance — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator
- FACTOROrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Manufacturer
- FACTORAircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Damaged/degraded
- FACTORAircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Inadequate inspection
Safety recommendations
13 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program.
TO THE FEDERAL AVIATION ADMINISTRATION: After the action in Safety Recommendation A-16-34 is completed, require all 14 Code of Federal Regulations Part 135 operators to establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.
TO THE FEDERAL AVIATION ADMINISTRATION: In conjunction with Textron Aviation and Hawker 700- and 800-series training centers, develop and incorporate into Hawker 700- and 800-series pilot training programs a nonprecision approach procedure that aligns with the stabilized approach criteria outlined in Advisory Circular 120-71A and eliminates configuration changes at low altitudes.
TO THE FEDERAL AVIATION ADMINISTRATION: In conjunction with Textron Aviation and Hawker 700- and 800-series training centers, develop and incorporate into Hawker 700- and 800-series pilot training programs a definition of the term “landing assured” that aligns with the language of 14 Code of Federal Regulations 91.175(c)(1).
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations (CFR) Part 121, 135, and 91 subpart K operators and 14 CFR Part 142 training centers to train flight crews in the performance and use of the continuous descent final approach technique as their primary means for conducting nonprecision approaches.
TO THE FEDERAL AVIATION ADMINISTRATION: Issue a safety alert for operators describing the circumstances of this accident and reminding operators to ensure that current and accurate information is entered into weight-and-balance software programs used in their operations.
TO THE FEDERAL AVIATION ADMINISTRATION: Review the Safety Assurance System and develop and implement procedures needed to identify 14 Code of Federal Regulations Part 135 operators that do not comply with standard operating procedures.
TO THE FEDERAL AVIATION ADMINISTRATION: Review the problems with the quality of the cockpit voice recorder (CVR) data in this accident to (1) determine why the problems were not detected and corrected before the accident, despite the requirements in Federal Aviation Administration Order 8900.1 and the guidance in Safety Alert for Operators 06019, and (2) determine if the procedures in Advisory Circular (AC) 20-186 would have ensured that the CVR problems were identified and corrected before the accident, and if not, revise AC 20-186 to ensure that such problems will be identified and corrected.
TO TEXTRON AVIATION: Work with the Federal Aviation Administration and Hawker 700- and 800-series training centers to develop and incorporate into Hawker 700- and 800-series pilot training programs a nonprecision approach procedure that aligns with the stabilized approach criteria outlined in Advisory Circular 120-71A and eliminates configuration changes at low altitudes.
TO TEXTRON AVIATION: Work with the Federal Aviation Administration and Hawker 700- and 800-series training centers to develop and incorporate into Hawker 700-and 800-series pilot training programs a definition of the term “landing assured” that aligns with the language of 14 Code of Federal Regulations 91.175(c)(1).
TO SIMCOM AVIATION TRAINING AND FLIGHT SAFETY INTERNATIONAL: Work with the Federal Aviation Administration and Textron Aviation to develop and incorporate into Hawker 700-and 800-series pilot training programs a nonprecision approach procedure that aligns with the stabilized approach criteria outlined in Advisory Circular 120-71A and eliminates configuration changes at low altitudes.
TO SIMCOM AVIATION TRAINING AND FLIGHT SAFETY INTERNATIONAL: Work with the Federal Aviation Administration and Textron Aviation to develop and incorporate into Hawker 700-and 800-series pilot training programs a definition of the term “landing assured” that aligns with the language of 14 Code of Federal Regulations 91.175(c)(1).
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-16/03. On November 10, 2015, about 1453 eastern standard time (EST), Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), N237WR, departed controlled flight while on a nonprecision 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 postcrash 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 (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed from Dayton-Wright Brothers Airport (MGY), Dayton, Ohio, about 1413 and was destined for AKR.