Crash During Nonprecision Instrument Approach to Landing Execuflight Flight 1526 British Aerospace HS 125-700A, N237WR

NTSB Aircraft Accident Report interactions with the captain and the first officer were when he conducted the oral portions of their Part 135 Hawker 700A competency checks in J une and July of 2015, respectively.

The POI had not had the opportunity to go to CAE Simuflite in Dallas to observe Execuflight simulator training because of funding limitations and did not always know when the pilots went for training until after they com pleted their training. The POI stated that he had never had the opportunity to “sit through” ground school training at Execuflight. The POI considered Execuflight to be a “very good operator,” and, in general, he felt Execuflight did a “pretty good job.” A ccording to the POI, he was aware that the position of director of operations was vacant at the time of the accident and that Execuflight was in the process of trying to fill it. The POI stated that the chief pilot temporarily took over some of the duties and did an “excellent” job.

1.12 Additional Information 1.12.1 Recent Investigations with C ockpit V oice R ecorder Issues On August 16, 2015, a Cessna 172M, N1285U, and a North American Rockwell NA265 - 60SC (Sabreliner), N442RM, collided in midair about 1 mi northeast of Brown Field Municipal Airport, San Diego, California. The pilot (and sole occupant) of the Cessna and the two pilots and two mission specialists aboard the Sabreliner died; both airplanes were destroyed.

The Cessna was operating under the pr ovisions of 14 CFR Part 91, and the Sabreliner was operated as a public aircraft in support of the US Navy. The Sabreliner’s tape - based Fairchild GA - 100 CVR had fair to poor quality; specifically, old content was not fully erased before new content was wri tten to the tape, causing audio “shadows” of prior flights that confounded usability of the most recent recording.

On March 13, 2014, US Airways flight 1702, an Airbus A320, N113UW, experienced a nose landing gear collapse after the captain aborted the tak eoff at Philadelphia International Airport, Philadelphia, Pennsylvania. Of the 149 passengers, two reported minor injuries; the airplane sustained substantial damage. US Airways was operating the airplane under the provisions of 14 CFR Part 121 as a regul arly scheduled passenger flight. The investigation determined that the CVR’s cockpit area microphone channel was not working before the accident.

On February 5, 2014, Trans States Airlines flight 3395, an Embraer 145EP, N802HK, landed hard at Memphis Inter national Airport, Memphis, Tennessee. There were no injuries, and the airplane sustained substantial damage. Trans State Airlines was operating the airplane under the provisions of 14 CFR Part 121 as a regularly scheduled passenger flight. The investigati on determined that the CVR’s cockpit area microphone channel was not working before the accident.

More information about this accident, NTSB case number WPR15MA243A/B, can be found by accessing the Aviation Accident Database at www.ntsb.gov .

More i nformation about this accident, NTSB case number DCA14MA081, can be found by accessing the Aviation Accident Database at www.ntsb.gov .

More information about this accident, NTSB case number DCA14FA058, can be found by accessing the Aviation Accident Database at www.ntsb.gov .

NTSB Aircraft Accident Report On January 7, 2013, a Japan Airlines Boeing 787, JA829J, that was parked at a gate at Logan International Airport, Boston, Massachusetts, experienced an APU b attery fire (NTSB 2014a). There were no injuries, and the airplane sustained minor damage. The airplane had arrived from Narita International Airport, Narita, Japan, as a regularly scheduled passenger flight conducted under the provisions of 14 CFR Part 12 9. Due to design and installation issues, t he audio obtained from the enhanced airborne flight recorder was poor quality . Although the poor quality of the audio recording did not impact the investigation, the NTSB concluded that it could impede future inve stigations. Therefore, the NTSB issued Safety Recommendations A - 14 - 126 and - 127 to the FAA; these recommendations are currently classified “Open — Acceptable Response.” On March 4, 2008, a Cessna 500, N113SH, struck large birds, causing it to enter a steep descent and crash about 2 minutes after takeoff from Wiley Post Airport, Oklahoma City, Oklahoma (NTSB 2009b). The two pilots and three passengers died, and the airplane was destroyed by impact forces and postcrash fire. The airplane was operated under the provisions of 14 CFR Part 91. The investigation determined that the CVR was inoperative before the accident.

On February 1, 2008, a North American Rockwell NA - 265 - 80, N3RP, was substantially damaged when it collided with three other airplanes while taxiin g for departure at FXE . An airport tug driver received minor injuries. The airplane was being operated under the provisions of 14 CFR Part 91. The investigation determined that the CVR was inoperative before the accident.

1.12.2 Continuous Descent Final A pproach Technique and Stabilized Approach According to FAA AC 120 - 71A, “Standard Operating Procedures For Flight Deck Crewmembers,” dated February 27, 2003, a nonprecision IFR approach is stabilized when all of the following criteria are maintained from 1, 000 ft height above touchdown to landing in the touchdown zone: 1. The airplane is on the correct track.

2. The airplane is in the proper landing configuration.

3. After the FAF, the pilot flying requires no more than normal bracketing corrections to maintain the c orrect track and desired profile (3° descent angle, nominal) to Safety Recommendation A - 14 - 126 asked the FAA to require Boeing to improve the quality of (1) the enhanced airborne flight recorder radio/hot microphone channels by using the maximum available dynamic range of the individual channels and (2) the cockpit area microphone airborne recordings by increasing the crew conversation signals over the ambient background noise. Safety Recommendation A - 14 - 127 asked the FAA to either remove the current exception to European Organization for Civil Aviation Equipment ED - 112A, “Minimum Operational Performance Specification for Crash Protected Airborne Recording Systems,” chapter I - 6 in Technical Standard Order 123B, “Cockpit Voice Recorder Equipment,” or provide installers and certifiers with specific guidance to determine whether a cockpit voice recorder installation would be acceptable.

More information about this accident, NTSB case number NYC08LA091, can be found by acce ssing the Aviation Accident Database at www.ntsb.gov .

NTSB Aircraft Accident Report landing within the touchdown zone. Level - off below 1,000 ft height above touchdown is not recommended.

4. The airplane speed is within the acceptable range specified in the approved operating man ual used by the pilot.

5. The rate of descent is no greater than 1,000 fpm.

 If an expected rate of descent greater than 1,000 fpm is planned, a special approach briefing should be performed.

 If an unexpected, sustained rate of descent greater than 1,000 fpm is encountered during the approach, a missed approach should be performed. A second approach may be attempted after a special approach briefing, if conditions permit.

6. Power setting is appropriate for the landing configuration selected and is within the permissible power range for approach specified in the approved manual used by the pilot.

On January 20, 2011, the FAA issued AC 120 - 108, “Continuous Descent Final Approach [CDFA],” to promote the technique of a stable continuous descent path to the MDA in lieu of the traditional step - down or “dive and drive” type of nonprecision approach. The CDFA technique (or constant - angle - of - descent technique) is consistent with the stabi lized approach procedures in AC 120 - 71A and entails flying the final approach as a continuous descent, without level - off, from an altitude at or above the FAF minimum crossing altitude to a point about 50 ft above the landing runway threshold. According to the AC, “stepdowns flown without a constant descent will require multiple thrust, pitch, and altitude adjustments inside the … FAF. These adjustments increase pilot workload and potential errors during a critical phase of flight.” The AC stated that the advantages of the CDFA technique included the following: 1. Increased safety by employing the concepts of stabilized approach criteri a and procedure standardization 2. Improved pilot situational awareness and reduced pilot workload 3. Improved fuel efficiency by minimizing the low - altitude level flight time 4. Reduced noise level by minimizing the leve l flight time at high thrust s ettings 5. Procedural similarities to APV [approach procedure with vertical guidance] an d precision approach operations 6. Reduced probability of infringement on required obstacle clearance du ring the final approach segment Execufli ght training guidance did not incorporate the use of the CDFA technique on nonprecision approaches. While several CAE Simuflite instructors indicated that they may teach CDFA as a technique, there was no formal instruction on CDFA.

NTSB Aircraft Accident Report Execuflight stated in a July 20, 2016, letter to the NTSB that it notified the FAA on January 21, 2016, of its intent to require the use of CDFA on all nonprecision approaches conducted in Hawker 700 - and 800 - series airplanes and include CDFA in its approved training program for these airplanes. The letter also stated that CDFA will be required on all of its fleets and that Execuflight will audit its contract training facilities to verify that the training is provided.

NTSB Aircraft Accident Report

2. Analysis

2.1 General The flight crew was properly certifica ted and qualified in accordance with federal regulations and company requirements. No evidence was found indicating that the flight crew’s performance was affected by toxins, alcohol or other drugs , or medical conditions. Postaccident examination of the ai rplane found no evidence of any preimpact structural, engine, or system failures.

When the flight contacted Akron approach control, the approach controller asked the pilot to advise when he had the automated weather for AKR. The pilot responded that they w ere “in the process of copying the weather.” According to FAA procedures, the controller should have followed up and verified that the pilot received the weather information, but he did not do so.

However, the controller’s omission was inconsequential beca use the CVR recording confirmed that the flight crew listened to the AKR ASOS and received the weather information. The NTSB concludes that the air traffic controller ’ s handling of the flight was not a factor in this accident.

The security video shows tha t fire erupted immediately upon impact. The autopsy and toxicological reports indicate that the pilots and two of the passengers survived the initial impact.

However, they did not exit the airplane. The NTSB concludes that the impact forces of the accident were survivable for some occupants, but the immediate and rapidly spreading postcrash fire likely precluded the possibility of escape .

2.2 Accident Sequence 2.2.1 Preapproach The CVR recording indicated that during the flight, the first officer was the P F. This was contrary to Execuflight’s informal practice of the captain acting as the PF on all revenue legs with passengers on board and the first officer acting as PF on legs that did not have revenue passengers on board. According to the former director of operations, he considered the practice a “safety proposal” in place at Execuflight and considered each first officer’s ability on a “one - on - one basis.” According to the chief pilot, it was “captain’s discretion” to decide if the first officer was compet ent to fly an instrument approach. Thus, although the captain’s decision to allow the first officer to act as PF on the accident leg was contrary to Execuflight’s informal safety practice, the decision was at the captain’s discretion.

The flight departed MGY about 1413, and at 1426:09, the flight crew began preparing for the approach into AKR by attempting to receive the weather at AKR via the ASOS broadcast.

However, the flight crew received the automated weather observation for Fairfield County Airport, Lancaster, Ohio, located about 108 mi southwest of AKR, which indicated a visibility of 10 mi and a ceiling of 1,100 ft overcast, considerably better than the current AKR visibility of 1 3/4 mi in mist and overcast ceiling of 700 ft agl. It is likely that the flight crew had previously listened to the MGY ASOS, which had the same frequency as Fairfield County Airport’s ASOS, and failed NTSB Aircraft Accident Report to change frequencies before they attempted to listen to the AKR weather. The flight crew did not immediately recognize the ir error, and the correct weather for AKR was not recorded on the CVR until 1437:39.2, about 11 min 30 seconds later.

At 1427:27.8, the first officer said, “I’ll let you brief it [the approach] to me,” and, contrary to Execuflight GOM guidance, which speci fied that before starting an approach, the PF will brief the PM, the captain responded, “okay” and began the approach briefing. For the PF, briefing the approach to be conducted reinforces the approach requirements and procedures to perform as the pilot fl ying the approach. As stated in the Execuflight GOM, “crew briefings help to standardize an operation and stimulate planning, supervision, teamwork, integrity, and redundancy. They are also a mechanical means of requiring a pilot to consider factors that m ight otherwise be overlooked.” At 1433:38.8, the first officer said, “okay. so we go down twenty three. then down to (what’s the minimums?),” and the captain responded, “four seventy three.” The localizer approach to runway 25 had an MDA of 1,540 ft msl, and the height of the MDA above the runway 25 TDZE was 473 ft. Thus, these statements indicated that both pilots were referring to the AKR localizer 25 approach chart at this time. The flight crew then discussed the missed approach procedure, followed by a discussion of the overcast height above the ground.

At 1436:26.9, the first officer said, “the minima for this approach [is] fifteen twenty,” followed by, “which is ground. where is the ground. five oh one right?” A review of the AKR RNAV GPS 25 approach chart showed that it listed 1,520 ft msl as the MDA for one version of the approach and 501 ft agl as the height above the ground of the MDA for another version of the approach. Thus, the first officer’s comments indicated that at this time, he was using th e RNAV 25 approach chart for reference during the approach briefing instead of the localizer 25 chart. The captain did not correct the first officer, and the correct height above the ground of the MDA for the localizer 25 approach was not verbalized agai n until 1441:24.9, about 5 minutes later.

At 1436:40, while the first officer was discussing the MDA with the captain, radar data recorded the flight at 10,000 ft msl with an estimated airspeed of about 298 knots. This speed was 48 knots higher than the ma ximum speed of 250 knots required by 14 CFR 91.117 below 10,000 ft msl. No comments were recorded by the CVR at this time about airspeed, and it is likely that both pilots failed to recognize their lack of compliance with the 250 - knot speed restriction as they descended below 10,000 ft msl.

The first officer made several statements that indicated he had an incorrect understanding of the weather minimums required to begin an instrument approach; he referred to the ceiling height as the controlling weather mi nimum, rather than the visibility. At 1437:09.7, the first officer stated, “yeah I understand. but we can shoot it. we can shoot because the overcast reporting * eight hundred.” At 1437:32.7, he stated, “the cloud base is from the ground. from the ground do we get minimums for us.” Title 14 CFR 91.175(c)(2) prohibits operation below the DH or MDA unless the flight visibility is not less than the visibility prescribed in the standard instrument approach being used. Title 14 CFR 135.225 requires that the latest weather report issued by a weather reporting facility at an airport must indicate that weather conditions are at or above the authorized IFR landing minimums for that airport before a pilo t may begin an instrument approach.

NTSB Aircraft Accident Report After listening to the AKR ASOS, at 1439:22.4, the captain stated that the ceiling was 600 ft overcast and the visibility was 1 1/2 mi (which was greater than the required visibility of 1 1/4 mi for the Hawker 700A). The capta in and first officer then discussed the visibility and determined that they had the required minimum visibility to start the approach as indicated by the captain’s comment at 1439:40.7, “alright we are visibility we got it.” The captain became confused as to whether the approach briefing had been completed as indicated by his comment to the first officer at 1440:25.0, “did you do my approach (brief)?” This was likely because the captain did not enforce the SOP that required the PF, in this case the first o fficer, to brief the approach.

At 1441:08.8, almost 5 minutes after the initial erroneous reference to the RNAV 25 approach chart, the first officer said, “the minima is five hundred and ten,” followed by the captain questioning “localizer?” At this point the first officer apparently realized that he was referencing the RNAV approach chart and not the localizer approach chart because, at 1441:24.9, he correctly stated the height above the ground of the MDA for the localizer 25 approach as “four seventy thr e e.” The flight crew’s approach briefing was unstructured, inconsistent, and began before the crew had the most current weather at AKR on which to base the approach brief. Further, the flight crew never completed the approach briefing, and critical items r equired by the Execuflight GOM , such as the field elevation, minimum sector altitude, missed approach point, type of approach (step - down), and runway lighting , were never reviewed. This resulted in confusion about the expected weather and when the airplane would break out of the clouds on the approach. While determining when the airplane is expected to break out of the clouds can assist in managing the expectations of the approach, visibility is the controlling element of an approach, and the conversation b etween the two pilots led to an ambiguous expectation of when they would acquire visual contact with the ground and the runway environment.

The first item in Execuflight’s Hawker 700A Approach checklist called for the PM to state “approach brief” and the PF to respond, “complete.” The purpose of an Approach checklist is to ensure that the approach briefing has been completed and the cockpit is set up for the anticipated approach. Execuflight’s GOM stated that during airborne operations, the PF will call fo r the checklist; however, the CVR never recorded the first officer requesting the Approach checklist.

The GOM further stated that “checklist items will be read in a loud, clear voice and the proper response will be equally clear and understandable,” and up on completion of each individual checklist, the crewmember completing the checklist was to announce that the checklist is complete.

However, the CVR did not record the crew conducting the Approach checklist or announcing it was complete.

In summary, the fl ight crew failed to conduct a complete approach briefing and to accomplish the Approach checklist as required by Execuflight SOPs. The NTSB concludes that as a result of the flight crew’s failure to complete the approach briefing and the Approach checklist as per SOPs, the captain and first officer did not have a shared understanding of how the approach was to be conducted.

NTSB Aircraft Accident Report 2.2.2 Localizer Approach About 1444, the approach controller instructed the flight crew to reduce speed to 200 knots and descend to 4, 000 ft msl. About 2 minutes later, the controller notified the flight crew that they were following a slower airplane on the approach and issued a further speed reduction to 170 knots and a descent to 3,000 ft msl. At 1447:09.1, the controller gave the fli ght a heading of 280° to intercept the localizer course for runway 25. At 1447:47.4, the first officer told the captain that he was going to “drag every (thing),” indicating he planned to begin configuring the airplane for landing, likely in an attempt to reduce speed as they followed the slower airplane to the airport.

Based on the first officer’s statement, it is likely that, at this time, the flaps were set to 25°; however, the change in flap setting was not accompanied by a callout from either crewmemb er.

At 1448:14.3, the captain said, “we got nine degrees pitch up,” indicating that he noticed the first officer flying with a high pitch attitude, which was likely a further attempt by the first officer to reduce speed. At 1448:27.0, the CVR recorded the sound of the landing gear extending.

Extension of the landing gear was not accompanied by a callout from either crewmember.

Execuflight SOPs allowed the PF to make configuration changes such as lowering the landing gear or flaps; however, the SOPs specifi ed that, before making a configuration change, the PF was to make a callout to alert the PM to the forthcoming change. The NTSB notes that given the poor quality of the CVR recording, it is possible that the flight crew made some of the required callouts, but they were unintelligible.

At 1448:33.9, the captain said, with emphasis, “did you hear what he say? there is an airplane on the approach. (he is) slower than us. he hasn’t cancelled. we don’t know if he’s on the ground.” The captain was clearly concern ed that they would need additional spacing on the approach, and the first officer responded by slowing the airplane. Radar data indicate d that between 1448:30 and 1449:30, the airplane’s estimated airspeed decreased from about 150 to 125 knots.

At 1449:22 .9, when the flight was about 4 nm from the FAF, the approach controller advised the flight crew that the pilots of the slower airplane ahead had cancelled their IFR flight plan, cleared the flight for the localizer 25 approach, and instructed the flight t o maintain 3,000 ft msl until established on the localizer. According to radar data, the airplane was already established on the localizer when the approach clearance was issued and , consistent with the minimum altitude for that segment of the approach, co uld 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 airpla ne, the captain made several comments about the airplane’s decaying speed. At 1449.41.3, the captain said “look you’re going one twenty. you can’t keep decreasing your speed** -- .” The first officer was apparently unaware of his speed because he responded “no. one tw -- . how do you get one twenty?” The first officer may have believed that he was allowed to slow to V or 124 knots, but, at that moment, the airplane was REF still at flaps 25°, and according to Execuflight SOPs, should have been flying no slower than V + 20 knots or 144 knots. The first officer’s speed reduction placed the airplane in danger of REF an aerodynamic stall if the speed continued to decay, but the first officer apparently did not realize NTSB Aircraft Accident Report it. At 1449:56.1, the captain said “that’s what I’m saying. if you keep decreasing your speed -- ,” the first officer interrupted “but why?” and the captain continued “because we gonna stall. I don’t want to sta -- .” The first officer’s lack of awareness of his configuration and speed should have been an indication to the captain that the first officer was having difficulty flying the airplane in IMC and was not sufficiently familiar with the nonprecision ap proach procedures on the Hawker 700A to execute the approach safely. It was apparent that the first officer had lost situational awareness of the approach, and the circumstances were demanding more than his capabilities; however, the captain allowed the first officer to continue flying the approach. The NTSB concludes that before the airplane reached the FAF, when the first officer reduced airspeed and placed the airplane in danger of encountering a stall, the captain should have taken control of the airplane or called for a missed approach, but he did not do so.

At 1450:21.6, the approach controller ins tructed the flight to change to the local advisory frequency. At 1450:39.8, the captain made a position report on the local advisory frequency, and at 1450:53.9, one of the pilots of the preceding slower airplane stated, “hey guys. ah we just landed on the loc. and uh broke out right at minimums (right at a) mile.” This voluntary pilot report indicated that the ceiling was near the MDA of 1,540 ft msl or 473 ft agl, and the visibility was possibly below the 1 1/4 mi visibility required for the approach. Sin ce this visibility report was not an official observation, the accident flight was authorized to continue the approach. The captain acknowledged the transmission, but the flight crew did not discuss the weather that was reported; such a transmission should have heightened the crew’s awareness that they needed to execute the approach flawlessly or consider executing a missed approach.

At 1451:00.9, the first officer requested “full flaps” (45°). The first officer’s decision to use flaps 45° was contrary to Execuflight’s Hawker 700A nonprecision approach profile that required the airplane to be flown at flaps 25° until after descending to the MDA and landing was assured. It was also contrary to the training both pilots received on nonprecision approaches at C AE Simuflite. However, the captain did not question the first officer’s decision to conduct the approach with flaps 45°. Also, the captain failed to make the “flaps selected 45°” and “flaps indicate 45°” callouts as required by Execuflight SOPs. Further, a fter configuring the airplane for landing, the flight crew was required to accomplish the Landing checklist per Execuflight SOPs, and, although the captain began to recite the checklist at 1451:06.7, the flight crew never completed it.

At 1451:13.6, the fi rst officer reduced the power, and the airplane, which had been level about 3,000 ft msl, began to descend. At 1451:20, the airplane reached an altitude of about 2,900 ft, an airspeed of 115 knots, and a descent rate of about 1,000 fpm, which is the maximu m descent rate for an approach to be considered stabilized according to FAA AC 120 - 71A. At 1451:31.3, the first officer said, “alright we go to minimums,” indicating the airplane was crossing the FAF and could now descend to the MDA. The captain did not ma ke a “final fix” callout as required by Execuflight SOPs. According to radar data, the airplane crossed the FAF at 1451:33 at an airspeed of 109 knots and an altitude of about 2,700 ft, which was about 400 ft above the minimum crossing According to the manufacturer, at a gross weight of 22,286 lbs, the airplane’s stall speed with flaps 25° and gear extended was about 102 knots.

NTSB Aircraft Accident Report altitude. Because th e airplane was high on the approach, it was out of position to use a normal descent rate of 1,000 fpm to the MDA.

The airplane’s rate of descent increased rapidly, and at 1451:43, the airplane reached a descent rate of about 2,000 fpm, at an altitude of a bout 2,300 ft, and an airspeed of 118 knots. The high descent rate was likely due to the first officer’s attempt to salvage the approach by increasing the rate of descent, exacerbated by the increased drag resulting from the improper flaps 45° configuratio n. At 1451:56.6, the captain said, “on localizer. you’re diving. you’re diving. don’t dive. two thousand feet per minute buddy.” The first officer interjected, “yeah,” and the captain continued, saying “two thousand feet per minu - don’t go two thousand fee t per minute,” and again at 1452:07.3, “don’t go two thousand feet per minute.” At no time did he 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 cap tain failed to make the required 1, 000 ft, 500 ft, 200 ft, and 100 ft to minimums callouts required by Execuflight SOPs, which would have alerted the first officer to his altitude relative to the MDA, and he likely also failed to notice that the airspeed w as below V as he made no comment about it.

REF Radar data indicated that the airplane reached the MDA about 1452:13; at that time, the airplane’s airspeed was about 113 knots , and its rate of descent had decreased to about 830 fpm.

Upon reaching the MDA, t he captain did not call out “minimums” as required by Execuflight SOPs. At 1452:17.0, the captain reported that he saw the ground , and, at 1452:20.5, he said, “keep going,” although he made no reference to visually acquiring the PAPI or runway environment as required by 14 CFR 91.175(c)(1) for descent below the MDA. The first officer did not verbally respond to the captain’s command to “keep going” when arriving at the MDA, yet he complied with it and continued the descent, indicating his continued loss of situational awareness on the approach and his sole reliance on the captain’s instructions.

Execuflight SOPs for a stabilized approach required that a missed approach be executed if the airplane was not within a defined approach window when within 500 ft above the TDZE.

The ap proach window parameters included a descent rate less than 1,000 fpm, an airspeed no less than V (124 knots), and the appropriate flap configuration (25°). Although the descent rate had REF decreased to about 830 fpm, the airspeed was too slow at 113 knots, and the airplane was improperly configured with full flaps. Thus, upon reaching the MDA (which was 473 ft above the TDZE), the airplane was not within the defined approach window, and the flight crew should have executed a missed approach. The NTSB conclu des that when the airplane reached the MDA, the approach was not stabilized, and the captain should have called for a missed approach according to SOPs, but he did not do so.

Rather than calling for a missed approach, at 1452:27.3, about 14 seconds after the airplane descended below the MDA, the captain said “okay level off guy,” indicating that he wanted the first officer to stop his descent. The captain’s instruction to level off was followed immediately by the sound of the stick shaker, indicating that the airplane was nearing an aerodynamic stall.

Analysis of radar data indicated that just before radar contact was lost at an altitude of about According to the airplane’s flight manual, the stick shaker is set to operate at an indicated airspeed of 7% to 9% above stalling speed.

NTSB Aircraft Accident Report 1,300 ft msl, the airplane was likely in a stalled condition as indicated by an estimated airspeed of 98 knots and an estimated AOA of 21°, which exceeded the critical AOA of 15.5°. About 7 seconds after the captain’s instruction to level off, the CVR recorded the first sounds of impact.

Further evidence that the airplane was in a stalled condition at impact was p rovided by the AOA indicator that was found postaccident with its indicator needle within the stall band.

Leveling off required an increase in pitch and power to arrest the descent rate while maintaining airspeed . Because the flight crew had lost awareness of airspeed and allowed the airspeed to decay below V , there was little margin for error. Also, because the airplane was at REF flaps 45° instead of flaps 25°, the first officer needed to increase the power substantially more than he had during his trainin g on nonprecision approaches to compensate for the additional drag due to the higher flap setting. Maintaining altitude and airspeed at flaps 45° required a fuel flow of about 1,150 lbs per hour per engine, which was significantly more than the 800 lbs pe r hour per engine that Execuflight pilots were trained to apply to level the airplane at the MDA when conducting nonprecision approaches at flaps 25°. Additionally, depending on the descent power setting, there could have been some delay between the first officer’s movement of the thrust levers and an engine power increase . The NTSB concludes that , w hen attempting to arrest the airplane’s descent, the first officer did not appropriately manage pitch and thrust control inputs to counter the increased drag fr om the 45° flap setting, which resulted in an aerodynamic stall .

Throughout the approach, both pilots repeatedly failed to follow SOPs, which are intended to minimize operational errors; however, the captain was ultimate ly responsib le for demand ing a more professional and disciplined tone in the cockpit and ensur ing the safety of the flight. Although the captain clearly recognized that the first officer was having difficulty flying the approach, he did not intervene either before the airplane reache d the FAF when he noted the first officer was not maintaining the proper airspeed or after the airplane passed the FAF when he noted that the first officer was exceeding the proper vertical speed. Rather, the captain inappropriately adopted the duties of a flight instructor and did so ineffectively as demonstrated by his failure to ensure the safety of flight as he coached the first officer through the approach. The NTSB concludes that the captain’s failure to enforce adherence to SOPs and his mismanagement of the approach placed the airplane in an unsafe situation that ultimately resulted in the loss of control.

2.3 Standard Operating Procedures and Flight Data Monitoring As previously discussed, the flight crew failed to adhere to company policy and negle cted numerous SOPs in performing the approach. The crew’s deficiencies included the following:  The captain (the PM) agreed to brief the approach to the first officer (the PF), as opposed to the PF briefing the PM as specified in the GOM.

 The approach briefing was not completed.

 The Approach checklist was not completed.

According to the manufacturer, at a gross weight of 22,286 lbs, the airplane’s stall speed with flaps 45° and gear extended was about 98 knots.

NTSB Aircraft Accident Report  Aircraft configuration changes were made without the required callouts.

 Instead of remaining at flaps 25° until after reaching the MDA and landing was assured, the flight crew prematurely set flaps 45°.

 The captain did not make numerous required callouts, including the “checklist complete” callout for the landing checklist; the “final fix” callout when the airplane reached the FAF; the 1,000 ft, 500 ft, 200 ft, and 100 ft t o minimums callouts; and the “minimums” callout when the airplane reached the MDA.

 Upon reaching the MDA, the approach was unstabilized, which mandated a missed approach, but the flight crew continued the approach.

 The captain instructed the first officer to continue to descend below the MDA without the runway environment in sight and landing assured.

SOPs are widely recognized as a basic element of safe aviation operations. Well designed cockpit procedures are an effective countermeasure against operation al errors, and disciplined compliance with SOPs, including strict checklist discipline, provides the basis for effective crew coordination and performance. The NTSB has repeatedly cited casual cockpit discipline and inadequate compliance with SOPs as contr ibuting factors to accidents (NTSB 2003, NTSB 2006a, NTSB 2006c, NTSB 2006d, NTSB 2007a, NTSB 2007b, NTSB 2009a, NTSB 2010a, NTSB 2011a, NTSB 2011b, and NTSB 2015). Operational data confirm the importance of strict compliance with SOPs for safe operations. For example, industry data show that pilots who intentionally deviated from SOPs were three times more likely to commit other types of errors, mismanage errors, and find themselves in undesired situations compared with pilots who did not intentionally dev iate from procedures.

The NTSB’s investigation of the crash of East Coast Jets flight 81, a Hawker 800A, N818MV, on July 31, 2008, in Owatonna, Minnesota, found that, if East Coast Jets, as a Part 135 operator, had been required to develop SOPs and its p ilots had been required to adhere to them, many of the deficiencies demonstrated by the pilots during the accident flight (which included inadequate checklist discipline and failure to conduct an approach briefing) might have been corrected. Therefore, the NTSB issued Safety Recommendation A - 11 - 20, which asked the FAA to require 14 CFR Part 135 and 91 subpart K operators to establish, and ensure that their pilots adhere to, SOPs (NTSB 2011a).

In a November 18, 2013, response, the FAA agreed that there was no explicit regulatory requirement that Part 135 or Part 91 subpart K operators develop and employ formalized SOPs.

However, the FAA stated that its policy and guidance repeatedly emphasized the use of SOPs and required all Part 135 and Part 91 subpart K o perators to either develop their own SOPs or to use SOPs found in the manufacturers’ operating manuals. As a result, the FAA believed that little could be gained by developing further guidance or other materials about SOPs for Part 135 and Part 91 subpart K operators. However, to remind these operators of the importance of adhering to SOPs, the FAA developed and, on July 9, 2012, issued SAFO 12003, which reminded all Part 135 The data came from the LOSA Collaborativ e, a network of researchers, safety professionals, pilots, and line representatives collaborating to provide, among other things, oversight and implementation of line and air operational safety audits (LOSA) and a forum of information exchange regarding th ese audits. More information is available at http://losacollaborative.org/ .

NTSB Aircraft Accident Report certificate holders and Part 91 subpart K program managers of the criticality of u sing SOPs during all phases of flight. The FAA believed that it had fully addre ssed Safety Recommendation A - 11 - 20 and planned no further action.

On March 21, 2014, the NTSB replied that, despite the guidance that had been issued, some Part 135 operators s till were not establishing and requiring their pilots to adhere to SOPs. However, because the FAA regarded its action as complete, the NTSB classified Safety Recommendation A - 11 - 20 “Closed — Unacceptable Action.” Nevertheless, procedural noncompliance contin ues to concern the NTSB, and the NTSB included the issue of “Strengthen Procedural Compliance” on its 2015 Most Wanted List.

In this case, Execuflight had established SOPs, but the flight crew consistently failed to follow them. As noted in FAA AC 120 - 71A, a lack of firm implementation of SOPs by management poses a danger in that flight crews “too easily become participants in an undesirable double standard condoned by instructors, check airmen, and managers. Flight crews may end up doing things one way to satisfy training requirements and checkrides but doing them another way in ‘real life’ during line operations.” Although the accident pilots had recently successfully completed Execuflight’s initial pilot training program, their performance during the acci dent flight appears to represent an example of the risk described by the AC.

Execuflight had no means to monitor the daily operation of its airplanes, identify operational deficiencies (such as noncompliance with SOPs), and correct those deficiencies befo re an accident occurred. Absent continual surveillance of an operation through en route inspections by company check airmen, the only means an operator can use to consistently and proactively monitor its line operations is through comprehensive data collec tion over the entirety of its operation, which can be accomplished through a flight data monitoring (FDM) program.

In Part 121 operations, many airlines voluntarily have FDM programs known as flight operations quality assurance programs, as described in F AA AC 120 - 82, “Flight Operational Quality Assurance.” FDM programs consist of a system or combination of systems that record an aircraft’s flight performance and operational data. These data are downloaded, evaluated, and used to identify and mitigate risk s by modifying operational and maintenance procedures, providing feedback to pilots in training, and highlighting areas in which additional training may be needed.

The accident airplane was equipped with a CVR as required by 14 CFR 135.151 but was not req uired to and did not have an FDR. CVR review is typically restricted to accident investigations and is not used for FDM programs. In addition to this accident, the NTSB has investigated other Part 135 accidents in which operator s lacked the means to monito r routine flight operations (NTSB 2003, NTSB 2006c, NTSB 2009b, NTSB 2009c, NTSB 2010b, and NTSB 2011a).

As a result of an increase in fatal helicopter emergency medical service (HEMS) accidents in 2008, on September 24, 2009, the NTSB issued Safety Recomm endation A - 09 - 90, which asked the FAA to require HEMS operators to install flight data recording devices and establish a structured FDM program that reviews all available data sources to identify deviations from NTSB Aircraft Accident Report established norms and procedures and other p otential safety issues. On February 21, 2014, the FAA published a comprehensive final rule addressing many aspects of HEMS operations (NARA 2014) . The final rule included 14 CFR 135.607, “Flight Data Monitoring System,” which requires that a helicopter used in air ambulance operations conducted under Part 135 be equipped with an approved FDM system capable of recording flight performance data. However, the final rule did not require that all HEMS operators establish an FDM program. Pending such a require ment, on September 11, 2014, the NTSB classified Safety Recommendation A - 09 - 90 “Open — Acceptable Response.” The NTSB believes that, as demonstrated by this and many other accidents, all Part 135 operators have the same need for FDM programs as Part 135 HEMS operators. Had an FDM program been in place at Execuflight, failure of either pilot to follow SOPs on earlier flights might have provided Execuflight the opportunity to take corrective action that could have avoided the accident . The NTSB concludes that o perational FDM programs could provide Part 135 operators with objective information regarding the manner in which their pilots conduct flights and that a periodic review of such information could assist operators in detecting and correcting unsafe deviatio ns from company SOPs. Therefore, the NTSB recomme nds that the FAA require all 14 CFR Part 135 operators to install flight data recording devices capable of supporting a n FDM program. The NTSB further recommends that the FAA, after the action in Safety Rec ommendation A - 16 - 34 is completed, require all 14 CFR Part 135 operators to establish a structured FDM program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.

2.4 Organ izational Factors The operator is the first line of defense against procedural noncompliance by setting a positive safety attitude for pilots to follow and establishing organizational protections. In this accident, Execuflight had defined protections in pl ace , including reviewing the background of its incoming pilots, providing CRM training, and overseeing flight operations. However, as discussed in the following sections, these barriers were undermined by Execuflight’s lack of compliance and inappropriate implementation.

2.4.1 Pilot Hiring PRIA requires that, before allowing an individual to begin service as a pilot, a hiring air carrier must request, receive, and evaluate records from previous employers pertaining to that individual’s performance as a pilo t. The purpose of a PRIA background check is to ensure that More information about Safety Recommendation A - 09 - 90 can be found by accessing the Safety Recommendations link at www.ntsb.gov .

According to the FAA, records related to pilot performance encompass those records of an activity or event specifically related to an individu al’s completion of the core duties and responsibilities of a pilot, as assigned by the employer and established by the FAA, to maintain safe aircraft operations. Records of disciplinary action arising out of the pilot’s noncompliance with company policies unrelated to safe aircraft operations (for example, attendance, company dress codes, and other morality or behavior - based policies) are not the type contemplated by PRIA.

NTSB Aircraft Accident Report an air carrier has the information needed to make an informed decision about a pilot’s professional competence before hiring that individual.

According to the president of Execuflight, who was re sponsible for hiring all company personnel, the captain’s PRIA background check showed an “administrative issue” at his previous employer that was corrected, and his separation from the company was voluntary. However, this information was contrary to infor mation that the captain’s previous employer provided to the NTSB, which indicated that he was terminated due to his failure to attend scheduled recurrent training. Although PRIA did not require Execuflight to evaluate the captain’s employment termination ( because the reason did not pertain to his performance as a pilot), the conflicting information about the circumstances of the captain’s termination suggests that Execuflight management did not conduct a thorough review of the captain’s background.

The fir st officer’s PRIA background check records that Execuflight provided indicated that the first officer was terminated by his previous employer due to “unsatisfactory work performance.” The records included a letter from a check airman that detailed training difficulties that the first officer encountered during Boeing 737 ground school and simulator training. The president of Execuflight stated that he hired the first officer based on a recommendation from another pilot and a single flight he made with him. Regarding the first officer’s PRIA records, the president stated that he did not “really home in on him ” as he was hiring him as SIC .

The first officer’s recent and extensive training difficulties were well documented by his previous employer, and this doc umentation was included in the PRIA records and should have alerted Execuflight to conduct a thorough evaluation of the first officer’s abilities to operate as a pilot on their certificate. However, although Execuflight’s chief pilot stated that he was aw are of the first officer’s training difficulties and that he was “terminated involuntarily” from his previous employer, no one from Execuflight contacted the previous employer to discuss the training issues identified by the check airman.

Since the FAA has left the responsibility of determining a pilot’s professional competence solely with the operator hiring the pilot, it is important that the operator conduct a thorough examination of a pilot’s background to ensure the pilot is prepared and qualified to s afely operate an airplane under the operator’s certificate. This is the primary reason PRIA was enacted.

However, in this case, Execuflight’s evaluation of the PRIA records it obtained for both the captain and the first officer was cursory. Although the ca ptain’s termination for failing to attend training was not related to his competence as a pilot, the first officer’s recent training difficulties were substantial and should have raised concerns with Execuflight management about the first officer’s compete nce. The NTSB concludes that because Execuflight did not fully evaluate the information it had concerning the first officer’s significant training difficulties at his previous employer, the company missed an opportunity to determine if the first officer wa s fully capable of operating its airplanes safely.

2.4.2 C rew R esource M anagement Training AC 120 - 51E details methods and characteristics of effective CRM training. According to the AC, the components of effective CRM include initial indoctrination/awareness, recurrent practice and feedback, and continual reinforcement. While Execuflight addressed CRM in t he NTSB Aircraft Accident Report flight crew’s initial training, no evidence exists that recurrent practice and feedback or continual reinforcement were part of the company’s organizational practices.

Review of Execuflight’s CRM training program, which the captain and first officer completed separately about 4 months before the accident, revealed that the content consisted of a cursory review of the topics required by 14 CFR 135.330(a). Much of the content was largely copied and pasted from AC 120 - 51E’s Appendix 1, which discusses crew performance marker clusters. This appendix was provided to assist organizations with program and curriculum development; it was not designed as curriculum itself. In addition, the performance of the flight crewmembers on the CRM test was not appropriately assessed.

Upon completion of the training, each pilot was required to pass a 10 - question test with an uncorrected score of 80%. The uncorrected grades recorded on the captain’s and first office r’s answer sheets were 100% and 80%, respectively. However, according to the answers provided in the CRM manual, the captain’s and first officer’s actual uncorrected scores were 40% and 70%, respectively. The chief pilot initialed both answer sheets, and a corrected grade was recorded on the first officer’s answer sheet, indicating that the first officer received a review of the questions missed. However, no evidence exists that the captain received a review of the questions missed.

The Execuflight chief pi lot’s apparent dismissal of the captain’s CRM test results indicates a “check the box” approach by Execuflight to CRM training and minimizes the importance that CRM has in teamwork, communication, and safety. Areas of CRM in which the crewmembers were defi cient according to their CRM test results included responsibilities of the PIC, flight deck management, and aeronautical decision - making. Significantly, the captain’s errors during the flight were in these deficient areas, demonstrating that the CRM traini ng the crewmembers received was ineffective.

Also, AC 120 - 51E emphasizes the importance of crewmembers training together; however, during simulator training, the captain was paired with a pilot from a different operator, and the first officer was paired w ith an instructor. As a result, neither pilot had the opportunity to practice CRM with another Execuflight pilot before flying revenue flights. Further, Execuflight did not use scenario - based training and line - oriented flight training, which are noted in t he AC as effective ways to train and reinforce CRM. Finally, the company had no method of evaluating and providing feedback to improve CRM skills. The NTSB concludes that deficiencies in Execuflight’s CRM training program, including the cursory review of C RM topics, the lack of appropriate evaluation of CRM examinations, and the lack of continual reinforcement of CRM principles, resulted in the flight crew receiving inadequate CRM training.

Although both pilots had recently completed Execuflight’s CRM trai ning program, the ir performance during the accident flight was inconsistent with the skills and knowledge associated with effective CRM. Effective CRM incorporates elements of communication, decision - making, team - building, workload management, and situatio n awareness skills that can be used to operate the aircraft appropriately and adhere to SOPs, including checklists and callouts. As previously described, both the captain and the first officer neglected numerous SOPs throughout the accident flight. The ir a ctions revealed ineffective coordination and division of responsibility, failure to execute checklists and make callouts as required, and inadequate pilot briefings , all of which are indicative of poor CRM . In addition, neither the captain nor the first of ficer challenged the other on his noncompliance with SOPs, which is inconsistent with appropriate CRM practice. T he refore, NTSB Aircraft Accident Report the NTSB concludes that the flight crew did not demonstrate effective CRM during the accident flight.

2.4.3 Flight Operations Oversi ght Not only did the flight crew consistently fail to follow SOPs during the accident flight, they also deviated from SOPs regarding preflight planning on the accident flight and all prior flights of the 2 - day trip. Examples of these deviations include the lack of adherence to procedures on calculating passenger and baggage weights, filing alternate airports, and recording flight log information.

To ensure accuracy and verify that preflight planning was conducted properly by its pilots, the flight - locating procedures in the Execuflight GOM required that, before a flight was initiated, the operations management person on duty was to review weather, fuel, weight and balance, and verify that an appropriate flight plan was filed. When asked if he reviewed these items before the accident flight departed, Execuflight’s chief pilot, who was the operations management person on duty at the time of the accident, stated that he was kept abreast of the airplane’s movements through the “doors open” and “doors closed” text messages that he received from the crew. His answer implies that the chief pilot did not review the weather, fuel, weight and balance, and flight plan for the accident flight as required by company procedures; thus, there was no verification of the prefli ght planning for the accident flight or opportunity to correct mistakes made by the flight crew. Further, the NTSB found evidence indicating that Execuflight management’s disregard for the preflight planning requirements in its flight - locating procedures w as not limited to the accident flight.

A review of the Fltplan.com website records for the Execuflight account indicated that the weather page listing the MGY and AKR weather reports and forecasts was accessed at 0928 on the day of the accident. Because a ccess to the website account was via a common user name, it is unknown who reviewed the weather page, but it was likely one of the accident pilots. When the Fltplan.com weather page was accessed, the TAF for CAK, located 8 mi south of AKR, called for 4 mi visibility in light drizzle and mist and an overcast ceiling of 700 ft agl at the estimated time of arrival into AKR. Further, the area forecast for northern Ohio as amended by AIRMET Sierra update 3, issued at 0945, called for ceilings less than 1,000 ft agl and visibility below 3 mi i n mist and light precipitation.

Based on the CAK TAF and the AIRMET Sierra, an alternate airport was required to be filed on the flight plan for the accident flight. However, when the flight plan was filed at 1133, the captai n did not file an alternate airport for the flight contrary to 14 CFR 135.223 requirements.

Although it is not known what alternate airport the flight crew would have chosen had they complied with the requirements, even the most conservative fuel load esti mate for the accident airplane (using the flight crew’s planned fuel of 7,700 lbs) would have provided ample fuel for flight to multiple possible alternates (including a return to the departure airport, MGY) with the appropriate fuel reserves.

A review of the available past flight plans filed by the captain while operating as PIC for Execuflight between August 28, 2015, and November 10, 2015, revealed four other flights for which an alternate airport was required but not filed, including the flight before t he accident flight NTSB Aircraft Accident Report from LUK to MGY. This indicated a recent history on the part of the captain of failing to file an alternate airport on a flight plan as required by federal regulations. In addition, the captain’s history of failing to file an alternate a irport when one was required indicates that Execuflight management had a history of failing to verify that an appropriate flight plan was filed before departure of each flight as required by company procedures.

Review of the Ultra - Nav printouts and the ma nifest forms for all the flights of the 2 - day trip revealed multiple deviations from SOPs in the flight crew’s preflight procedures, including the following:  Instead of using actual weights when calculating weight and balance, the flight crew used a weight of 200 lbs for each passenger and a weight of 250 lbs for baggage on all flights of the 2 - day trip, including the accident flight.

 The flight crew used a fuel weight of 7,700 lbs for the accident flight, but if the airplane’s wing tanks were filled to cap acity at MGY as the flight crew requested, the fuel weight used should have been 8,160 lbs.

 For all five legs of the 2 - day trip before the accident flight, the weight - and - balance information on the Ultra - Nav printout did not match the weight - and - balance information entered on the flight log.

 The flight crew did not complete the flight log before departing on the accident flight.

Without the actual weights of each passenger and the baggage, it was not possible to accurately determine the weight of the airplane at takeoff from MGY. Estimates of the airplane’s takeoff and landing weights were calculated using the correct basic empty weight, the same passenger and baggage weights used by the flight crew, a takeoff fuel weight of 7,860 lbs (8,160 lbs less 300 lbs taxi burn), and the same en route fuel burn used by the flight crew (1,500 lbs). The estimated takeoff weight of 23,786 lbs exceeded the flight’s maximum takeoff weight (as limited by landing weight) of 23,500 lbs by 286 lbs, and t he estimate d landing weight of 22,286 lbs exceeded the airplane’s maximum landing weight of 22,000 lbs by 286 lbs. An exceedance of this magnitude likely would not have had a significant effect on aircraft performance. The NTSB concludes that although the flight crew ’s multiple deviations from SOPs concerning weight and balance on each flight of the 2 - day trip likely did not directly contribute to the accident, these deviations represent a pattern of routine disregard for SOPs.

The pattern of routine disregard for S OPs regarding preflight planning extended to Execuflight management. The flight crew’s consistent use of 200 lbs for the weight of each passenger and 250 lbs for the weight of the baggage on all previous flights of the 2 - day trip provided five opportunitie s before the accident flight for a manager reviewing the weight - and - balance calculations as required by company procedures to recognize that actual weights were not being used. However , no evidence exists that Execuflight management recognized or took any action to remedy this repeated disregard of company SOPs, just as they did not address the captain’s multiple failures to file an alternate airport when one was required. The NTSB concludes that Execuflight’s management had multiple opportunities to identi fy and correct the flight crew’s routine disregard for SOPs regarding preflight planning but failed to do so.

NTSB Aircraft Accident Report A further instance of Execuflight’s management neglecting to properly oversee its flight operations occurred during the first officer’s la st duty period before the accident trip. According to flight logs covering this duty period , on November 7 (3 days before the accident flight), the fir st officer came on duty at 1500 and flew the return leg of a 2 - day trip, arriving at FXE at 2006. The first offi cer then immediately began an overnight trip, departing FXE at 2040 . His last Part 135 flight on the overnight trip ended at 0715 on November 8. Upon completion of the flight at 0715, the first officer had only 7 hours 45 min of consecutive rest in the pre ceding 24 hours, which was below the 10 hours minimum consecutive rest required by both 14 CFR 135.267(d) and Execuflight’s GOM. Although Execuflight’s president asserted in sworn testimony that the first officer came on duty after the captain of the 2 - day trip (at 1715 on November 7) and actually had 10 hours rest, the sworn testimony of the captain of the 2 - day trip, hotel records, and a “doors closed” text message support the 7 hours 45 min of rest calculated from the flight logs.

Further, the captain o f the overnight trip was Execuflight’s chief pilot, and the operations management person on duty for the overnight trip was Execuflight’s president. According to the sworn testimony of Execuflight’s president, both the chief pilot and the president were aw are of the potential failure to meet rest requirements if the first officer completed the overnight trip.

Although the operations management person on duty was required by company procedures to ensure that each assigned pilot met rest requirements before t he flight departed, the evidence suggests that neither the chief pilot nor Execuflight’s president ensured that the first officer met the rest requirements of 14 CFR 135.267(d) before assigning him to fly the overnight trip.

The repeated deviations from so und operational practices identified in this investigation indicate a culture of complacency and disregard for rules, signifying the need for strong leadership and positive role models to reinforce a positive safety culture. SOPs were implemented as a coun termeasure against human error ; however , the efficacy of these initiatives is dependent on compliance (Helmreich 2000; Helmreich et al. 2001). A strong organizational safety culture embeds the importance of compliance with SOPs as a countermeasure against the occurrence of consequential human error that tends “to reduce the margin of safety and increase the probability of accidents or incidents” (ICAO 2002). Therefore, the NTSB concludes that Execuflight’s casual attitude towards compliance with standards i llustrates a disregard for operational safety, an attitude that likely led its pilots to believe that strict adherence to SOPs was n ot required .

2.4.4 Safety Management System In addition to not rigorously following its own SOPs, Execuflight lacked an SMS, which has been recognized in the industry as an effective way to establish and reinforce a positive safety culture and identify deviations from SOPs so that they can be corrected. According to the FAA’s website, “SMS is the formal, top - down business - like approach to managing safety risk, which includes a systemic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures.” Although the FAA requires only More information can be found at www.faa.gov/about/initiatives/sms/faq .

NTSB Aircraft Accident Report 14 CFR Part 121 air carri ers to have an SMS, other sectors of the aviation industry are increasingly implementing SMS voluntarily .

The NTSB has investigated other recent Part 135 accidents where failures of organizational safety played a role. On February 14, 2014, a Cessna 210L, N732EJ, operated by Southern Seaplane, Inc., impacted terrain near Clay, Alabama, after the pilot lost control in night IMC.

The pilot and the passenger died, and the airplane was destroyed. The NTSB determined that contributing to the accident were the operator’s inadequate dispatch procedures, which did not prevent the pilot from flying beyond his duty day, flying at night for which he was not current, or flying in IMC for which he was not qualified by the company.

On November 29, 2013, the pilot of a C essna 208B, N12373, operated by Hageland Aviation, lost situational awareness in night IMC, resulting in controlled flight into terrain (CFIT) near St. Mary’s, Alaska. The pilot and three passengers died, and six passengers received serious injuries; the airplane sustained substantial damage. The NTSB determined that contributing to the accident were the operator’s inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel.

Th e St. Mary’s, Alaska, accident occurred 1 week after another accident involving the same operator in which a Beech 1900C, N575X, landed short of the runway in Deadhorse, Alaska, on November 22, 2013. The NTSB again cited as contributing factors the operat or’s inadequate procedures for operational control and flight release and its inadequate training and oversight of operational control personnel. These are examples of numerous Part 135 accidents and incidents in which the NTSB has determined that inadequa te operational safety oversight was a contributing factor. Each of these accidents may have been prevented if an SMS had been in place.

After the October 14, 2004, accident involving Pinnacle Airlines flight 3701, N8396A, in Jefferson City, Missouri, the NTSB issued Safety Recommendation A - 07 - 10, which asked the FAA to require SMS programs for Part 121 operators (NTSB 2007a). This recommendation was classified “Closed — Acceptable Action” after the FAA’s final rule requiring SMS programs for Part 121 air car riers was issued on January 8, 2015, and became effective on March 9, 2015.

Because the benefits of SMS programs are not limited to Part 121 operators, the NTSB has also advocated for SMS programs for Part 91 business operators and Part 135 HEMS operators.

After the July 10, 2007, crash of a Cessna 310R, N501N, operated by the National Association for Stock Car Auto Racing under Part 91 in Sanford, Florida, the NTSB issued Safety Recomme ndation A - 09 - 16, which asked the FAA to develop a SAFO encouraging all Part 91 More information about this accident, NTSB case number ERA14FA120, can be found by accessing the Aviation Accident Database at www.ntsb.gov .

More information about this accident, NTSB case number ANC14MA008, can be found by accessing the Aviation Accident Database at www.ntsb.gov .

More information about this accident, NTSB case number ANC14LA007, can be fo und by accessing the Aviation Accident Database at www.ntsb.gov .

NTSB Aircraft Accident Report business operators to adopt SMS programs that include sound risk management practices. The FAA addressed this recommendation by issuing Information for Operators message 11010 on April 11, 2011, and, on September 12, 2011, the NTSB classified the recommendation “Closed — Acceptable Action.” As the result of an increase in fatal HEMS accidents in 2008, the NTSB issued Safety Recommendation A - 09 - 89, which asked the FAA to require all HEMS operators to implement SMS programs that include sound risk man agement practices. In a September 24, 2014, response, the FAA stated that its goal was to require SMS for all Part 135 operators but that it did not have the resources to address a rule for SMS for HEMS operators at that time. Therefore, on December 5, 20 14, the NTSB classified Safety Recommendation A - 09 - 89 “Closed — Unacceptable Action.” When the FAA issued its final rule in January 201 5 requiring SMS programs for 14 CFR Part 121 air carriers, the key requirements for an SMS were modularized in newly - creat ed 14 CFR Part 5, “Safety Management Systems.” In its final rule, the FAA stated that its intent in developing Part 5 was to establish a uniform standard that could be extended to apply to other operating parts, including Part 135 (NARA 2015) . However, in the 20 months that have elapsed since Part 5 was established, the FAA still has not issued a notice of proposed rulemaking to address SMS for Part 135 operators.

The safety benefits of SMS programs have been demonstrate d by Part 121 carriers and Part 135 H EMS operators who have voluntarily implemented SMS programs (Bergin 2013; Buckner 2013). Because Part 135 operations often involve carrying passengers for hire, the FAA is responsible for ensur ing that Part 135 operators have adequate safety protections in place for the flying public. Accidents related to organizational culture are preventable, yet, as can be seen by this accident and the other Part 135 accidents mentioned above (Clay, Alabama; St. Mary’s Alaska; and Deadhorse, Alaska), Part 135 accidents t ied to operational safety issues are pervasive.

R ulemaking in this area is long overdue, given that fatal Part 135 accidents related to organizational culture continue to occur, that the FAA has created a modular set of requirements to support application of SMS rulemaking beyond Part 121 carriers, and that the FAA has previously stated its intent to expand SMS rulemaking to Part 135 operators. The NTSB concludes that SMS programs can benefit all 14 CFR Part 135 operators because they require the operators to incorporate formal system safety methods into their internal oversight programs . Therefore, the NTSB recommends that the FAA require all 14 CFR Part 135 operators to establish SMS programs.

More information about Safety Recommendation A - 09 - 16 can be found by acce ssing the Safety Recommendations link at www.ntsb.gov .

Information for Operators message 11010 encouraged general aviation (Part 91) operators “to incorporate Safety Management Systems as a standard business practice regardless of type of aircraft operated.” More information about Safety Recommendation A - 09 - 89 can be found by accessing the Safety Recommendations link at www.ntsb.gov .

NTSB Aircraft Accident Report 2.5 Fa tigue Evaluation The NTSB evaluated a number of criteria, including recent sleep, sleep quality, and circadian factors, to determine whether the flight crewmembers were experiencing fatigue at the time of the accident.

2.5.1 Captain’s Fatigue Evaluation Th ere was no evidence of circadian disruption, sleep disorders, or medical conditions for the captain that indicated poor sleep quality. His work schedule for the accident trip and his preceding trip complied with Part 135 rest requirements.

According to PE D records, the captain had a sleep opportunity of about 9 hours on the night before the accident. However, during the second, third, and fourth nights before the accident, the captain’s sleep opportunities were less than 6 hours 15 min each night. Although no data were available to establish the captain’s normal amount of sleep need, if the captain required the amount recommended by the National Sleep Foundation (7 to 9 hours for adults ages 26 to 64), less than 6 hours sleep for 3 consecutive nights would constitute a sleep debt (Hirshkowitz 2015).

PED logs indicate that nap opportunities may have been available to the captain during the day on November 7 and 8 (3 and 2 days before the accident). However, even if these gaps in PED usage were used for naps, research suggests that fragmented sleep (which may be more likely during daytime naps) is less restorative than unfragmented sleep (Stepanski 2002). Further, although research suggests that well placed naps can improve alertness for up to 24 hours, any na ps taken by the captain 2 to 3 days before the accident would likely not have affected his alertness on the day of the accident (Dinges et al. 1987). Also, if the captain had accumulated a sleep debt, research indicates that fatigue - related effects can lin ger after 1 night of near - normal recovery sleep such as that possibly experienced by the captain on the night before the accident (Sallinen et al. 2008; Belenky 2003; Van Dongen et al. 2003). However, because no data were available regarding the captain’s normal sleep needs, the existence of a sleep debt at the time of the accident could not be determined.

The captain’s behavior during the accident flight could have been consistent with the known effects of fatigue. For example, the captain’s decision to al low the first officer to fly the airplane with revenue passengers aboard was contrary to common company practices and could indicate impaired decision - making. Additionally, his continued decisions not to take control of the aircraft from the first officer despite the first officer’s failure to maintain proper airspeed and descent rate could indicate the inability to adapt behavior to accommodate new information.

Although these actions may have been influenced by fatigue, they can also be attributed to other factors identified in this investigation such as poor CRM and procedural intentional noncompliance. Further, the captain’s lack of adherence to the company’s SOPs was so pervasive that, even if fatigue were present, it was most likely not the only factor affecting his performance.

The NTSB concludes that the captain’s degraded performance during the flight was consistent FAA SAFO 07006 def ines procedural intentional noncompliance as the deliberate failure to follow regulations, SOPs , and established company polic y.

NTSB Aircraft Accident Report with the effects of fatigue, but insufficient evidence exists about his normal sleep needs to determine whether he was fatigued at the t ime of the accident.

2.5.2 First Officer’s Fatigue Evaluation There was no evidence of sleep disorders or medical conditions for the first officer that indicated poor sleep quality in the days before the accident. Although his work schedule for the accide nt trip complied with Part 135 rest requirements, as discussed in section 2.4.3, the flight logs for the first officer's preceding trip s showed an insufficient rest period before a n overnight trip on November 7.

Acc ording to the flight logs, the first off icer did not have an opportunity to rest on the night of November 7, which could have led to fatigue caused by circadian disruption. The first officer’s sleep opportunities on the nights of November 8 and 9 were ample and aligned with normal circadian rhyt hm, as they occurred during local night time; however, no data were available regarding the actual amount of time he spent sleeping within those periods.

It is possible that residual effects of fatigue due to circadian disruption can exist for days follow ing the disruption (Gallo and Eastman 1993). PED usage data showed that during the day on November 8, the first officer had a maximum sleep opportunity of 7 hours 44 min; however, it was not continuous, as it was interrupted at its midpoint by the first of ficer sending a text message.

Thus, the first officer’s ability to get restorative sleep during this period would have been affected by both the challenge of obtaining sleep during the day and the interruption that resulted in fragmented sleep . In additio n, the captain of the first officer ’s 2 - day trip (on November 6 and 7 ) stated during sworn testi mony that the first officer called him on the evening of November 8 and said that he was feeling fa tigued from the overnight trip , which had ended early that day.

Considering the circadian disruption due to the overnight trip on November 7, the fragmented rest period during the day on November 8, and the self - report of fatigue on November 8, the first officer was likely experiencing fatigue during the accident flight.

The first officer exhibited some behaviors consistent with fatigue, such as fixation and degradation of visual scan, difficulty reasoning as demonstrated by his confusion over the MDA, and poor performance on flying the aircraft to standards (Caldw ell et al. 2004). Although these behaviors are consistent with the effects of fatigue, they are also consistent with the performance deficiencies that the first officer displayed during simulator training at his previous employer.

Further, as with the capt ain, the first officer’s behavior can also be attributed to other factors identified in this investigation , such as poor CRM and procedural intentional noncompliance. The NTSB concludes that , as a result of circadian disruption and Execuflight’s improper c rew scheduling that did not provide the first officer with adequate rest for his preceding trip, the first officer was likely experiencing fatigue ; however, the extent to which fatigue contributed to his deficient performance on the accident flight could n ot be determined .

NTSB Aircraft Accident Report 2.6 Operational Issues 2.6.1 Hawker 700A Nonprecision Approach Procedure Although landings are authorized at flaps 25°, the normal landing flap configuration on the Hawker 700A is flaps 45°. For precision approaches (such as an ILS appr oach), Execuflight Hawker 700A procedures call for the pilot to select flaps 45° at glideslope intercept, which typically occurs when the airplane is above 1,000 ft agl, and fly the remainder of the approach at flaps 45° to landing. Precision approaches, t herefore, do not require a flap configuration change as the airplane descends on the final segment of the approach. However, for nonprecision approach e s (such as the accident approach), Execuflight Hawker 700A pilots are trained to use a step - down technique that does require a flap configuration change during the final segment of the approach.

Descent is initiated at the FAF with flaps 25°, and, upon arrival at the MDA, the airplane is leveled off u ntil it reaches the point of “runway assured.” The pilot then selects flaps 45° and descends to the runway.

Since many nonprecision approaches, such as the AKR localizer 25 approach, have MDAs about 400 to 500 ft agl, the step - down technique entails a con figuration change, accompanied by changes in pitch and power, when the airplane is well below 1,000 ft agl. Selecting flaps 45° in the Hawker 700A causes a nose - down change in pitch attitude and, because of the extra drag, an increase in rate of descent un less power is added. The NTSB notes that the accident pilots did not perform the accident approach as they were trained; rather, they selected flaps 45° before reaching the FAF, which further increased the difficulty of the step - down approach because it re quired them to maintain level flight with flaps 45° upon reaching the MDA.

Configuration changes below 1,000 ft agl are contrary to the definitions of a stabilized approach provided in AC 120 - 71A and AC 120 - 108. One of the criteria listed in AC 120 - 71A for an approach in IMC to be considered stabilized is that the airplane must be in the proper landing configuration from 1,000 ft height above touchdown to landing in the touchdown zone.

AC 120 - 108 characterizes a stabilized approach as “maintaining a stable approach speed, descent rate, vertical flightpath, and configuration to the landing touchdown point” and states that the airplane should “depart the FAF configured for landing and on the proper approach speed, power setting, and flightpath.” When questione d as to what constituted a stable approach, CAE Simufli te Hawker instructors provided varying definitions, some of which conflicted with the criteria listed in AC 120 - 71A.

The NTSB found that all Hawker 700A pilots receiving instruction at CAE Simuflite, FlightSafety, and SimCom, which are the three largest Part 142 training centers in the United States offering Hawker 700 - and 800 - series training, are being trained to conduct nonprecision approaches using the same step - down technique that Execuflight’s pi lots were taught. The NTSB concludes that the nonprecision approach procedure that many Hawker 700 - and 800 - series pilots are trained on does not meet the stabilized approach criteria published in AC 120 - 71A. Therefore, the NTSB recommends that the FAA, i n 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 outline d in AC 120 - 71A and eliminates configuration changes at low altitudes.

NTSB Aircraft Accident Report Further, no definition of “runway assured” was found in the HS 125 - 700A Flight Manual, Execuflight GOM, Execuflight Training Manual, or Execuflight SOPs, and the Execuflight chief pilo t and CAE Simuflite Hawker instructors provided various definitions for the term, ranging from when the runway was in sight to when the wheels touched down on the runway. Some of the definitions provided appeared to conflict with 14 CFR 91.175(c)(1), which states, regarding descending below the MDA, that no pilot may operate an airplane below the MDA unless it “is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuver s, and for operations conducted under part 121 or part 135 unless that descent rate will allow touchdown to occur within the touchdown zone of the runway of intended landing.” The NTSB concludes that many Hawker 700 - and 800 - series pilots are receiving inc onsistent training regarding the meaning of “landing assured” that may conflict with the language of 14 CFR 91.175(c)(1). Therefore, the NTSB recommends that the FAA, in conjunction with Textron Aviation and Hawker 700 - and 800 - series training centers, de velop 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 CFR 91.175(c)(1).

2.6.2 Continuous Descent Final Approach Technique As described in section 1.12.2 , CDFA is a specific technique for flying the final approach segment of a nonprecision instrument approach as a continuous descent, without level - off, from a specific altitude near the FAF to a point about 50 ft above the l anding runway threshold.

AC 120 - 1 08 recommends the use of CDFA in lieu of the step - down type of nonprecision approach that Execuflight pilots were trained to conduct, which can lead to unstabilized approaches because of multiple thrust, pitch, and altitude adjustments inside the FAF. As n oted in the AC, the CDFA technique requires no specific aircraft equipment other than that specified by the nonprecision approach procedure, and, as noted by the International Civil Aviation Organization (ICAO), it minimizes the risk of unstabilized approa ches and CFIT.

The NTSB has long been a proponent of the CDFA technique for nonprecision approaches.

After the November 12, 1995, crash involving American Airlines flight 1572, a McDonnell Douglas MD - 80, N566AA, which struck trees while on approach to Bra dley International Airport, in Windsor Locks, Connecticut, the NTSB issued Safety Recommendations A - 96 - 128 and - 132, which asked the FAA to develop, and encourage the use of, CDFAs for all airports served by commercial carriers. After the August 6, 1997, c rash involving Korean Airlines flight 801, a Boeing 747 - 300, HL7468, at Nimitz Hill, Guam, on final approach to A.B. Won Guam International Airport, Agana, Guam, the NTSB issued Safety Recommendations A - 00 - 11 through - 14, which asked the FAA to address the equipment and training needed for CDFAs. The FAA ICAO Doc 8168, vol. I, part I, amendment 3, 1.7.1, states, “Studies have shown that the risk of controlled flight into terrain (CFIT) is high on non - precision approaches. While the procedures themselves are not inherently unsafe, the use of the traditional step down descent technique for flying non - precision approaches is prone to error, and is therefore discouraged. Operators should reduce this risk by emphasizing training and standardization in vertical path control on non - precision approach procedures. Operators typically employ one of three techniques for vertical path contr ol on non - precision approaches. Of these, the continuous descent final approach (CDFA) technique is preferred.

Operators should use the CDFA technique whenever possible as it adds to the safety of the approach operation by reducing pilot workload and by le ssening the possibility of error in flying the approach.” NTSB Aircraft Accident Report took actions that satisfied these recommendations, and the NTSB classified them all “Closed — Acceptable Action” or “Closed — Acceptable Alternate Action.” On October 19, 2004, the pilots of Corporate Airlines flight 5966, a British Aerospace Jetstream 32, N875JX, failed to follow established standard procedures during a nonprecision approach at night in IMC, including their descent below the MDA before required visual cues were available, which continued until the airplane struck trees near Kirksville, Missouri. The NTSB concluded that the use of a CDFA technique, with its resultant stabilized, moderate rate - of - descent flightpath and obstacle approach clearance, would have better positioned the accident airplan e for a successful approach and landing. The NTSB issued Safety Recommendation A - 06 - 8, which asked the FAA to require all Part 121 and 135 operators to incorporat e the constant - angle - of - descent technique into nonprecision approach procedures and to emphasi ze the preference for that technique where practicable (NTSB 2006a).

On May 21, 2009, the FAA issued SAFO 09011, which recommended that Part 121 and 135 operators always use a constant - angle - of - descent stabilized approach technique when conducting nonpreci sion approaches. On January 20, 2011, the FAA issued AC 120 - 108 to promote the CDFA technique. On May 20, 2011, the FAA published a supplemental notice of proposed rulemaking (SNPRM), titled “Qualification, Service, and Use of Crewmembers and Aircraft Disp atchers,” which proposed a requirement for Part 121 operators to train and incorporate the CDFA technique into their nonprecision approach procedures (NARA 2011) .

On November 14, 2012, the NTSB indicated that it agreed with the FAA that if the final rule contained the proposed language in the SNPRM, it would satisfy Safety Recommendation A - 06 - 08 regarding Part 121 operators and that SAFO 09011 satisfied the recommendation regarding Part 135 operators. Therefore, pending the issuance of a final rule as desc ribed in the SNPRM and a review of information confirming that SAFO 09011 has been widely adopted by Part 135 operators, the NTSB classified Safety Recommendation A - 06 - 8 “Ope n — Acceptable Alternate Response.” However, the final rule, which was published on November 12, 2013, did not contain any requirements regarding nonprecision approach techniques (NARA 2013) .

On August 14, 2013, UPS flight 1354, an Airbus A300 - 600, N155UP, crashed short of runway 18 during a nonprecision localizer approach at night in IMC at Birmingham - Shuttlesworth International Airport, Birmingham, Alabama. Although the flight crew set up and briefed a CDFA approach, the flight crew executed a “dive and drive” approach. As a result of the investigation, the NTSB classified Safety Recomme ndation A - 06 - 8 “Closed — Unacceptable Action/Superseded” and issued Safety Recommendation A - 14 - 76, which asked the FAA to require POIs of Part 121, 135, and 91 subpart K operators to ensure that FAA - approved nonprecision instrument approach landing procedure s prohibit “dive and drive” as defined in AC 120 - 108 (NTSB 2014b).

In a December 24, 2014, response, the FAA stated that although the CDFA technique was the preferred method for accomplishing a nonprecision approach, it “does not concur that operators shou ld be prohibited from performing a dive and drive maneuver. In certain situations, primarily More information about Safety Recommendations A - 96 - 128 and - 132 and A - 00 - 11 through - 14 can be found by accessing the Safety Recommendations link at www.ntsb.gov .

NTSB Aircraft Accident Report dependent on weather conditions and runway alignment in combination with runway visibility, a dive and drive maneuver could benefit an operator.” The FAA further s tated that “dive and drive is prudent and safe when done correctly and under appropriate circumstances,” and that it would take no further action to address Safety Recommendation A - 14 - 76. On February 26, 2015, the NTSB classified Safety Recommendation A - 14 - 76 “Closed — Unacceptable Action.” While the FAA has indicated that it favors the use of CDFA, the technique is only in guidance material (AC 120 - 108), and operators are not required to incorporate the information into their manuals. In this case, Execuflig ht training guidance did not specify the use of CDFA on nonprecision approaches, and , although several CAE Simuflite instructors indicated they may teach CDFA as a technique, no formal instruction on using the CDFA technique was provided to Execuflight pil ots before the accident. After the accident, Execuflight voluntarily revised its training guidance and , on January 21, 2016, notified the FAA of its intent to require the use of CDFA on all nonprecision approaches conducted in Hawker 700 - and 800 - series ai rplanes and include CDFA in its approved training program for these airplanes.

The NTSB continues to believe that all air carriers should use CDFA and that the FAA must do more to ensure that operators incorporate the CDFA technique in their training and manuals and use it whenever possible. Based on the circumstances of this accident and many previous accidents, the NTSB concludes that despite the guidance in AC 120 - 108, many operators do not train their flight crews how to perform a CDFA and to use a CDF A whenever possible.

Therefore, the NTSB recommends that the FAA require 14 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 CDFA technique as their primary means for conducting nonprecision approaches.

2.6.3 Accuracy of Data Entered into Weight - and - Balance Software Execuflight pilots primarily c omputed their airplane’s weight and balance by means of the Ultra - Nav software program, which required that an airplane’s basic operating weight first be entered as a default weight. Entering the correct basic operating weight was critical since it include d the weights of the required crew, their baggage, and other standard items such as meals and potable water. However, according to the Ultra - Nav printouts for the accident airplane, its current basic operating weight of 14,276.92 lbs was not used on the ca lculations for the accident flight or any of the previous flights during the 2 - day trip. Instead, the flight crew used a default of the airplane’s basic empty weight of 13,815 lbs. Because this weight did not include the weight of the required crew, their baggage, and other items typically included in the basic operating weight, the use of this weight resulted in a n approximate 462 - lb underestimate of the airplane’s takeoff weight on each flight of the 2 - day trip.

It is unclear who at Execuflight incorrect ly entered the default basic operating weight into Ultra - Nav, as any crewmember who had access to the system could change the default. Once the erroneous entry was made, the chief pilot and the flight crew missed multiple opportunities to recognize and cor rect the error. The chief pilot did not recognize the error when the flight crew sent him the Ultra - Nav printout for each leg of the trip, and the flight crew did not recognize that their weight - and - balance calculations were based on an incorrect default e ntry.

NTSB Aircraft Accident Report Additionally, weight - and - balance documentation found at the accident site indicated an erroneous basic operating weight for the airplane of 13,976.92 lbs and indicated that the APU had been removed from the airplane. However, the APU had been reinsta lled and was present at the accident site. When the maintenance on the APU was completed in February 2015, the documentation showing the 13,976.92 - lb basic operating weight should have been replaced with documentation showing the actual basic operating wei ght of 14,276.92 lbs. The presence of the incorrect document on board the airplane meant that had the flight crew wanted to verify the default basic operating weight entered in the Ultra - Nav program using documentation on board the airplane, they would hav e done so using incorrect information. The NTSB concludes that Execuflight failed to ensure that correct weight - and - balance information was on board the airplane and entered into the company’s weight - and - balance software, which resulted in the flight crew underestimating the airplane’s takeoff weight on each flight of the 2 - day trip. Although, as previously discussed in section 2.4.3, the incorrect weight - and - balance information did not adversely affect the airplane’s performance during the accident flight, the NTSB is concerned that this type of error could have serious ramifications.

S oftware programs, such as Ultra - Nav, provide a useful tool for pilots to calculate weight - and - balance and performance information before flights. They help in eliminating err ors when using charted information, save time, and reduce pilot workload during preflight planning.

However, the information generated from these programs is only as good as the information first entered into the programs as defaults, and operators should regularly review their software program data to ensure that it contains the most current and accu rate information for weight - and - balance calculations. Therefore, the NTSB recommends that the FAA issue a SAFO describing the circumstances of this accident an d reminding operators to ensure that current and accurate information is entered into weight - and - balance software programs used in their operations.

2.7 F ederal A viation A dministration Oversight 2.7. 1 Oversight of Execuflight’s Flight Operations The POI’s primary surveillance of Execuflight operations came from review of Execuflight manuals and the periodic 14 CFR 135.299 line checks he would conduct on Execuflight pilots.

However, these line checks were not conducted during normal r evenue operations, and the line - check flights conducted on Execuflight pilots typically remained local in the Florida area.

More significantly, the Execuflight POI stated that he did not conduct en route inspections on Execuflight or any of the other Part 135 operations he overs aw.

FAA Order 8900.1, volume 6, chapter 2, section 9, “Safety Assurance System: Co ckpit En Route Inspections,” states, in part, the following: The primary objective of cockpit en route inspections is for an inspector to observe and evaluate the in - flight o perations of a certificate holder within the total operational environment of the air transportation system. En route inspections are one of the Federal Aviation Administration’s (FAA) most effective methods of accomplishing its air transportation surveill ance objectives and responsibilities.

NTSB Aircraft Accident Report These inspections provide the FAA with an opportunity to assess elements of the aviation system that are both internal and external to an operator.

Regarding crewmember observations, the order states that inspectors sh ould observe and evaluate the crew during each phase of flight, including an evaluation of crewmember adherence to approved procedures, proper use of all checklists, and adherence to sterile cockpit procedures.

Specifically, regarding the approach phase of flight, the order states that “procedures used during the selected approach (instrument or visual) should be accomplished as outlined in the operator’s maneuvers and procedures document” and lists the following 12 specific areas for inspectors to observe and evaluate: 1. Approach checklists 2. App roach briefings, as appropriate 3. Compliance with ATC clearances and instructions 4. Navigational tra cking/heading and pitch control 5. Airspeed control, reference speed for final approach (V ) REF 6. Flap and gear configuration sch edule 7. Use of FD [flight director ], autopilot, and autothrottles 8. Com pliance with approach procedure 9. Sinkrates 10. Stabilized approach in the full landing configuration 11. Flightcrew callouts and coordination 12. Transition to v isual segment, if applicable Significantly, in this accident, the flight crew was deficient in 10 of the 12 areas, and the cumulative results were catastrophic.

2.7.2 Oversight of Execuflight’s Pilot Training The FAA’s oversight system did not identify or address the deficiencies in Execuflight’s training that were discovered during this investigation. The FAA POI who had oversight responsibilities for Execuflight also oversaw 15 other certificates and characterized his workload as “very busy.” He periodically conducted line and ramp checks and would “sample” flight manifest and training records. The POI had oversight responsibilities for Execuflight since The two areas in which deficiencies were not identified in this accident were “compliance with ATC clearances and instructions” and “use of FD, autopilot, and autothrottles.” NTSB Aircraft Accident Report May 24, 2004, yet had never been to CAE Simuflite in Dallas to observe Execuflight simulator training. He had also never observed Execuflight in - house training, including the basic indoctrination course and the CRM training. The POI was unaw are that an audit of the Hawker 800XP training program for Execuflight pilots, required by Execuflight’s operations specifications, was 1 year ov erdue until the NTSB advised him of the discrepancy.

FAA Order 8900.1, volume 6, chapter 2, section 21, “Safety Assurance System: Training Program Inspections for Parts 121 and 135,” provides direction and guidance to be used by POIs for conducting trai ning program inspections. Section 21 states that “the inspector’s objective is to ensure that the operator’s training program complies with regulatory requirements and instructional methods are effective.” It identifies five primary inspection areas to be observed: training curriculums, courseware, instructional delivery methods, testing and checking methods, and specific topics (identified from Program Tracking and Reporting Subsystem archived data or other sources).

The POI used the services of two CAE Si muflite training cen ter evaluators to conduct check rides on Execuflight pilots; the evaluators would inform the POI of the pass/fail outcomes from each Execuflight pilot checkride. However, monitoring pass/fail statistics does not constitute comprehensive oversight of an operator’s training program or ensure that the operator’s training program complies with regulatory requirements and that instructional methods are effective, as outlined in FAA Order 8900.1. The POI never observed simulator or in - house tra ining at Execuflight and was not aware of the delinquent status of the operator’s own training audit program for one of its fleets. In addition, as previously discussed, maintenance records for the accident airplane contained discrepancies (regarding docum enting the removal and replacement of the APU), and the airplane’s weight - and - balance records showed an incorrect basic operating weight. Therefore, t he NTSB concludes that the FAA failed to provide adequate oversight of Execuflight’s pilot training, main tenance, and operations.

2.7.3 En Route Surveillance En route inspections can enhance the FAA’s oversight by providing an opportunity to observe the crew’s use of SOPs outside of the training and checking environment. The Execuflight POI relied primarily on line checks to conduct his operational oversight, yet line checks flown locally do not constitute the same evaluation of the operator within the total operational environment of the air transportation system as en route inspections during normal line o perations. Although t he FAA considers en route inspections one of its most effective assessment tools, the FAA does not require inspectors of Part 135 operators to accomplish this critical surveillance activity.

The operations specifications required Execuflight to c onduct the recurring audits at least once every 24 months and present each audit evaluation to the POI for review and acceptance.

The FAA’s principal main tenance inspector assigned to Execuflight was responsible for the oversight of these documents.

Unlike a 14 CFR 135.299 line check (which evaluates the pilot on a pass - fail basis, is documented in the pilot’s training file, and must be administered by an approved check airman or FAA inspector), an en route inspection is an assessment tool that allows an FAA inspector to observe and assess the operation as a whole.

NTSB Aircraft Accident Report As a result of the East Coast Jets accident in Owatonna, Minnesota, on July 31, 2008, the NTSB issued Safety Recommendation A - 11 - 30, which asked the FAA to require that Part 135 PIC line checks be conducted independently from other required checks and be c onducted on flights that truly represent typical revenue operations (NTSB 2011a). In an August 8, 2013, response, the FAA stated that it had reviewed existing policy and guidance regarding PIC line checks and the implications on inspector workload of the r ecommended action. The FAA’s review revealed that Part 135 flights can be sporadic and often occur long distances from FAA facilities. As a result, the FAA believed that the recommended action would be logistically problematic and would increase FAA worklo ad without a corresponding improvement in safety. The FAA believed that current guidance to POIs on line checks was appropriate and planned no further action. On November 7, 2013, the NTSB classified Safety Recommendation A - 11 - 30 “Closed — Unacceptable Actio n” because the FAA did not plan to address the safety problem identified in the accident. The NTSB concludes that this accident again shows that FAA guidance for POIs regarding conducting 14 CFR Part 135 PIC line checks on flights other than in regular rev enue service is not effective in identifying pilots who are not complying with SOPs.

As a result of the October 25, 2002, crash of a Raytheon (Beechcraft) King Air A100 while attempting to land in Eveleth, Minnesota, on December 2, 2003, the NTSB issued Safety Recommendation A - 03 - 51, which asked the FAA to conduct en route inspections and observe ground training, flight training, and proficiency checks at all Part 135 on - demand charter operations (NTSB 2003). In a November 20, 2008, response, the FAA stat ed that, although en route inspections are one of the most effective methods for surveillance of an operator, arbitrarily assigning a minimum number of en route inspections for all on - demand operations would not increase safety and would not be the best us e of its resources. Instead, the FAA believed that it should prioritize surveillance activities of its inspectors by identifying weaknesses or potential safety risks in operator performance and allowing inspectors to apply the appropriate level of surveill ance to any particular operator. The FAA developed the Surveillance Priority Index (SPI), a tool that provided a ranked order of assessed safety risks and was to be used as the basis for surveillance activities, identifying the amount of oversight and prio ritizing the timing of surveillance required for a particular operator. The FAA proposed use of the SPI as an alternative action to address the recommendation.

On July 31, 2009, the NTSB replied that the plans to devel op the SPI and require FAA Part 135 o n - demand inspectors to use the SPI to prioritize their oversight activities, including en route surveillance, and to conduct at least one en route inspection annually for each on - demand operator, was an acceptable alternate response. The NTSB also asked th at the FAA summarize the specific types of oversight activities conducted on Part 135 on - demand operators in the year before and the one after implementation of the SPI to learn how many en route inspections were conducted and the number of different opera tors for which at least one en route inspection was conducted. On August 4, 2010, the FAA published a change to Order 8900.1 that required FAA inspectors for Part 135 on - demand operators to use the SPI.

In an August 20, 2015, response, the FAA provided da ta regarding the number of Part 135 operators for which en route surveillance was conducted during fiscal years 2012, 2013, and 2014, and data regarding the number of collective times these operators were inspected. The FAA stated that it believed it had addressed Safety Recommendation A - 03 - 51 and planned no further action.

On November 19, 2015, the NTSB replied that , although the FAA had not supplied data NTSB Aircraft Accident Report documenting any changes in its oversight program for Part 135 on - demand operators as a result of impl ementing the SPI, the data it did supply showed that about 5% of all Part 135 operators received en route surveillance annually and that the number was declining each year.

Consequently, the NTSB classified Safety Recommendation A - 03 - 51 “Closed — Unacceptabl e Action.” The Execuflight POI stated that he did not know what pilots did in normal operations since he only got to see them during their 14 CFR 135.299 line checks. Had the POI conducted en route inspections of Execuflight flights, the problems with fai lure to follow SOPs, CRM, and other required flight deck procedures may have been discovered and corrected before the accident occurred. The NTSB notes that the requirements in FAA Order 8900.1 for the POI to use the SPI existed before this accident occurr ed, yet the SPI did not identify the widespread noncompliance with SOPs at Execuflight. The NTSB concludes that this accident illustrates that the FAA’s SPI was in effective in identifying 14 CFR Part 135 operators in need of increased surveillance.

In its August 20, 2015, response, the FAA had also indicated that it was implementing a new oversight system for Part 135, called the Safety Assurance System (SAS) and that SAS will replace the SPI. When this accident occurred, SAS had not been fully implemented for Part 135 operators. The NTSB concludes that the implementation of the SAS represents an opportunity to develop and use oversight procedures to identify and correct problems with failures of 14 CFR Part 135 operators to use SOPs. Therefore, the NTSB r ecommends that the FAA review the SAS and develop and implement procedures needed to identify 14 CFR Part 135 operators that do not comply with SOPs.

2.8 C ockpit V oice R ecorder Maintenance Procedures The 30 - minute tape recovered from the CVR was not damag ed or affected by impact forces or postcrash heat exposure; however, the quality of all recorded channels was poor. As a result, the transcript that was developed contained numerous fragmented phrases and passages where conversations were missing or uninte lligible. Additionally, the poor quality of the recording precluded a sound spectrum study from extracting definitive engine speeds from recorded background frequencies . The poor quality of the CVR recording was due, in large part, to electrical interferen ce, likely from the aircraft’s alternating current generator. This interference was likely the consequence of particular characteristics of the CVR installation and the age of the airplane.

The CVR quality issue may have been detected via functional checks performed with the engines running or by downloading and reviewing CVR content from an actual flight. However, checks of the CVR performed without the engines running would have missed the problematic electrical interference.

The problem with poor quality CVR recordings that were not detected and corrected is not limited to this accident. Including this investigation, at least seven NTSB investigations in the last 10 years have identified problems with CVR quality. In the August 16, 2015, midair collision in San Diego, California, the poor CVR quality was likely due to the improper maintenance of the NTSB Aircraft Accident Report CVR. Without proper maintenance, either the erase head did not function as designed or the magnetic tape became overly worn, causing old content not to be era sed before new content was recorded. The CVR quality issue may have been detected via more robust functional checks or by downloading and reviewing CVR content from an actual flight. In the other five cases noted in section 1.12.1, the inoperative CVR, ino perative components, or inoperative channels could have been detected with more robust maintenance, functional checks, or by downloading and reviewing CVR content from an actual flight.

The NTSB has previously issued recommendations concerning the need fo r CVR functional checks. As a result of its longstanding concerns about the availability of CVR information after reportable accidents and incidents, on August 29, 2002, the NTSB issued Safety Recommendation A - 02 - 25, which asked the FAA to require that ope rators of airplanes equipped with CVRs implement daily CVR test procedures to test the functionality of the CVR system before the first flight of each day, as part of an approved aircraft checklist.

On March 23, 2004, an Era Aviation Sikorsky S - 76A++ helicopter, N579EH, crashed into the Gulf of Mexico about 70 nm south - southeast of Scholes International Airport, Galveston, Texas. The captain, copilot, and eight passengers died, and the helicopter was destroyed by impact forces. The investigation reveal ed that the helicopter’s CVR had been improperly installed, and the functional check of the CVR after installation did not detect the faulty installation. As a result, on March 25, 2006, the NTSB classified Safety Recommendation A - 02 - 25 “Closed — Superseded” and issued Safety Recommendation A - 06 - 23, which asked the FAA to do the following: Require all operators of aircraft equipped with a cockpit voice recorder (CVR) to (1) test the functionality of the CVR before the first flight of each day as part of an approved aircraft checklist and (2) perform a periodic maintenance check of the CVR as part of an approved maintenance check of the aircraft. The CVR preflight test should be performed according to procedures provided by the CVR manufacturer and should inc lude listening to the recorded signals on each channel to verify that the audio is being recorded properly, is intelligible, and is free from electrical noise or other interference. The periodic maintenance check of the CVR should include an audio test fol lowed by a download and review of each channel of recorded audio. The downloaded recording should be checked for overall audio quality, CVR functionality, and intelligibility. (NTSB 2006b) In a July 7, 2006, response, the FAA stated that it would issue a S AFO advising ope rators to test the functionalit y of the CVR before the first flight of each day, and on November 8, 2006, the FAA issued SAFO 06019. In a November 8, 2014, response, the FAA stated that Order 8900.1 requires all pilots of aircraft equipped with a CVR to test the function of the CVR before the first flight of each day as part of an approved aircraft checklist. The FAA also stated that it had revised More information about this accident, NTSB case number WPR15MA243A/B, can be found by accessing the Aviation Accident Database at www.ntsb.gov .

More information about Safety Re commendation A - 02 - 25 can be found by accessing the Safety Recommendations link at www.ntsb.gov .

NTSB Aircraft Accident Report Order 8900.1, volume 4, chapter 14, section 9, paragraph 4 - 1553, subparagraph A, to state the following: A. Requirements of CVR Maintenance Procedures. The Avionics ASI [aviation safety inspector] is responsible for determining that the maintenance procedures ensure that tests are conducted according to procedures provided by the CVR manufacturer a nd shall include, at a minimum, listening to the recorded signals on each channel to verify that the audio is being recorded properly, is intelligible, and is free from electrical noise or other interference.

On December 12, 2014, the NTSB classified Safet y Recommendation A - 06 - 23 “Closed — Acceptable Action.” The NTSB noted t wo FAA actions as supporting the closure status: (1) the issuance of SAFO 06019 and (2) the revision to Order 8900.1 that assigned the avionics inspector responsibility for ensuring that CVR maintenance procedures included listening to the recorded signals on each channel.

SAFO 06019 may have helped identify the accident airplane’s CVR problem; however, Execuflight’s POI indicated he was not familiar with the SAFO and that it was only a re commended action. Although the FAA indicated in SAFO 06019 that the POI is responsible for checking that approved aircraft checklists include a requirement for all pilots of aircraft equipped with a CVR to test the function of the CVR before the first flig ht of each day, Execuflight’s POI appears to have been unaware of this requirement, and Order 8900.1 does not provide guidance similar to the SAFO for the POI.

Although Order 8900.1 states that the avionics inspector (in this case, the PAI) is responsible for determining that an operator’s maintenance procedures ensure that tests are conducted according to procedures provided by the CVR manufacturer, Execuflight’s PAI indicated that most CVR functional checks actually performed do not conform to the CVR man ufacturer’s procedures. In addition, although Order 8900.1 explicitly states that the functional check should ensure that the recorded signal “is free from electrical noise or other interference,” Execuflight’s PAI was unable to adequately perform this che ck and did not find the problem identified in this investigation : the loud tone of about 400 Hz and associated harmonics. The NTSB concludes that, had an adequate functional test of the CVR installed on the accident airplane been performed with the engines running or by downloading and reviewing CVR content from an actual flight, the poor quality of the CVR recording may ha ve been detected and corrected.

On July 21, 2016, the FAA issued AC 20 - 186, “Airworthiness Operational Approval of Cockpit Voice Recorde r Systems,” which provides guidance for compliance with FAA regulations related to required CVR systems. The AC canceled AC 25.1457 - 1A, “Cockpit Voice Recorder Installations,” dated November 3, 1969, which was in effect at the time of the accident. In its December 8, 2015, comments on the FAA’s draft AC 20 - 186, the NTSB stated that despite the FAA’s amendments to Order 8900.1 and its issuance of SAFO 06019, “the NTSB continues to receive CVRs that have supposedly passed operational tests using comprehensive self - test and automatic fault reporting but still have unusable audio content. The NTSB also continues to receive unusable audio content from CVRs that have passed maintenance functional tests; however, such tests did not include a download that would hav e confirmed proper operation.” The NTSB also indicated that the new AC provided an opportunity to strengthen the guidance (1) for flight crews NTSB Aircraft Accident Report about performing robust operational tests by listening to recorded audio using existing CVR design features and ( 2) for operators about performing a robust functional test that specifically includes CVR download and review.

Had AC 20 - 186 been in effect before this accident, the quality problems with this CVR, may have been identified. Therefore, the NTSB recommends t hat the FAA review the problems with the quality of the CVR data in this accident to (1) determine why the problems were not detected and corrected before the accident, despite the requirements in FAA Order 8900.1 and the guidance in SAFO 06019, and (2) de termine if the procedures in AC 20 - 186 would have ensured that the CVR problems were identified and corrected before the acc ident, and if not, revise AC 20 - 186 to ensure that such problems will be identified and corrected.

NTSB Aircraft Accident Report

3. Conclusions

3.1 Findings 1. The f light crew was properly certificated and qualified in accordance with federal regulations and company requirements. No evidence was found indicating that the flight crew’s performance was affected by toxins, alcohol or other drugs , or medical conditions.

2. P ostaccident examination of the airplane found no evidence of any preimpact structural, engine, or system failures.

3. The air traffic controller ’ s handling of the flight was not a factor in this accident.

4. As a result of the flight crew’s failure to complete the approach briefing and the Approach checklist as per standard operating procedures, the captain and first officer did not have a shared understanding of how the approach was to be conducted.

5. Before the airplane reached the final approach fix, when the f irst officer reduced airspeed and placed the airplane in danger of encountering a stall, the captain should have taken control of the airplane or called for a missed approach, but he did not do so.

6. When the airplane reached the minimum descent altitude, th e approach was not stabilized, and the captain should have called for a missed approach according to standard operating procedures, but he did not do so.

7. When attempting to arrest the airplane’s descent, the first officer did not appropriately manage pitch and thrust control inputs to counter the increased drag from the 45° flap setting, which resulted in an aerodynamic stall .

8. The captain’s failure to enforce adherence to standard operating procedures and his mismanagement of the approach placed the airplan e in an unsafe situation that ultimately resulted in the loss of control.

9. The impact forces of the accident were survivable for some occupants, but the immediate and rapidly spreading postcrash fire likely precluded the possibility of escape .

10. Operational f light data monitoring programs could provide 14 Code of Federal Regulations Part 135 operators with objective information regarding the manner in which their pilots conduct flights, and a periodic review of such information could assist operators in detect ing and correcting unsafe deviations from company standard operating procedures.

11. Because Execuflight did not fully evaluate the information it had concerning the first officer’s significant training difficulties at his previous employer, the company missed an opportunity to determine if the first officer was fully capable of operating its airplanes safely.

NTSB Aircraft Accident Report 12. The flight crew did not demonstrate effective crew resource management during the accident flight.

13. Deficiencies in Execuflight’s crew resource management (CRM) training program, including the cursory review of CRM topics, the lack of appropriate evaluation of CRM examinations, an d the lack of continual reinforcement of CRM principles, resulted in the flight crew receiving inadequate CRM training.

14. Although the flight crew’s multiple deviations from standard operating procedures (SOPs) concerning weight and balance on each flight of the 2 - day trip likely did not directly contribute to the accident, these deviations represent a pattern of routine disregard for SOPs.

15. Execuflight’s management had multiple opportunities to identify and correct the flight crew’s routine disregard for stan dard operating procedures regarding preflight planning but failed to do so.

16. Execuflight’s casual attitude towards compliance with standards illustrates a disregard for operational safety, an attitude that likely led its pilots to believe that strict adhere nce to standard operating procedures was n ot required .

17. Safety management system programs can benefit all 14 C ode of Federal Regulations Part 135 operators because they require the operators to incorporate formal system safety methods into their internal oversight programs.

18. The captain’s degraded performance during the flight was consistent with the effects of fatigue, but insufficient evidence exists about his normal sleep needs to determine whether he was fatigued at the time of the accident .

19. As a result of circadian disruption and Execuflight’s improper crew scheduling that did not provide the first officer with adequate rest for his preceding trip, the first officer was likely experiencing fatigue ; however, the extent to which fatigue contributed to his deficient performance on the accident flight could not be determined .

20. The nonprecision approach procedure that many Hawker 700 - and 800 - series pilots are trained on does not meet the stabilized approach criteria published in Advisory Circular 120 - 71A.

21. Man y Hawker 700 - and 800 - series pilots are receiving inconsistent training regarding the meaning of “landing assured” that may conflict with the language of 14 Code of Federal Regulations 91.175(c)(1).

22. Despite the guidance in Advisory Circular 120 - 108, many o perators do not train their flight crews how to perform a continuous descent final approach (CDFA) and to use a CDFA whenever possible.

23. Execuflight failed to ensure that correct weight - and - balance information was on board the airplane and entered into the company’s weight - and - balance software, which resulted in NTSB Aircraft Accident Report the flight crew underestimating the airplane’s takeoff weight on each flight of the 2 - day trip.

24. The Federal Aviation Administration failed to provide adequate oversight of Execuflight’s pilot trainin g, maintenance, and operations .

25. This accident again shows that Federal Aviation Administration guidance for principal operations inspectors regarding conducting 14 Code of Federal Regulations Part 135 pilot - in - command line checks on flights other than in r egular revenue service is not effective in identifying pilots who are not complying with standard operating procedures.

26. This accident illustrates that the Federal Aviation Administration’s Surveillance Priority Index was in effective in identifying 14 Code of Federal Regulations Part 135 operators in need of increased surveillance.

27. The implementation of the Safety Assurance System represents an opportunity to develop and use oversight procedures to identify and correct problems with failures of 14 Code of F ederal Regulations Part 135 operators to use standard operating procedures.

28. Had an adequate functional test of the cockpit voice recorder (CVR) installed on the accident airplane been performed with the engines running or by downloading and reviewing CVR c ontent from an actual flight, the poor quality of the CVR recording may have been detected and corrected.

NTSB Aircraft Accident Report 3.2 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 environm ent, 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; a nd the Federal Aviation Administration’s insufficient oversight of the company’s training program and flight operations.

NTSB Aircraft Accident Report

4. Recommendations

To the Federal Aviation Administration: Require all 14 Code of Federal Regulations Part 135 operators to install fli ght data recording devices capable of supporting a flight data monit oring program.

(A - 16 - 34 ) 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.

(A - 16 - 35 ) Require all 14 Code of Federal Regulations Part 135 operators to establish safety manageme nt system programs. (A - 16 - 36 ) 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 stabi lized approach criteria outlined in Advisory Circular 120 - 71A and eliminates configuration changes at low altitudes. (A - 16 - 37 ) In conjunction with Textron Aviation and Hawker 700 - and 800 - series training centers, develop and incorporate into Hawker 700 - an d 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). (A - 16 - 38 ) Require 14 Code of Federal Regulations ( CFR ) Part 121, 135, and 91 subpart K operators a nd 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. (A - 16 - 39 ) Issue a safety alert for opera tors describing t he 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. (A - 16 - 40 ) 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. (A - 16 - 41 ) 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 C ircular (AC) 20 - 186 would have ensured that the CVR problems were identified and corrected before the accident, NTSB Aircraft Accident Report and if not, revise AC 20 - 186 to ensure that such problems will be identified and corrected. (A - 16 - 42 ) 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 Advi sory Circular 120 - 71A and eliminates configuration changes at low altitudes. (A - 16 - 43 ) 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 p rograms a definition of the term “landing assured” that aligns with the language of 14 Code of Federal Regulations 91.175(c)(1). (A - 16 - 44 ) To Hawker 700 - and 800 - series training centers: 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 . (A - 16 - 45 ) 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). (A - 16 - 46 ) BY THE NATIONAL TRANSPORTATION SAFETY BOARD CHRISTOPHER A. HART ROBERT L. SUMWALT Chairman Member BELLA DINH - ZARR EARL F. WEENER Vice Chairman Member Adopted : October 18, 2016 NTSB Aircraft Accident Report

Board Member Statement

Member Robert L. Sumwalt filed the following concurring statement on October 25, 2016.

I believe the organization that chartered this aircraft expected to get a professionally managed aircraft. I suspect they expected to get a professionally flown aircraft. And, I further believe they expected that when the regulator, the Federal Aviation Ad ministration, issued an Air Carrier Certificate to Execuflight, they expected the FAA to provide adequate surveillance of Execuflight. Tragically, as this investigation found, those charter customers did not get what they expected or deserved in any of the se respects. Their expectations were based on a house of cards that created an illusion of safety The facts of this investigation revealed a litany of failures – both in the organization and in the cockpit.

Execuflight. The investigation found that Exec uflight had a “casual attitude towards standards” and compliance. Further, the report noted, “The repeated deviations from sound operational practices identified in this investigation indicated a culture of complacency and disregard for rules…” During a post - accident interview, Execuflight’s sales agent, a 4 ½ - year employee of Execuflight, told investigators: “I think we're very safe. Our maintenance is great.” (see Interview Summaries , page 389). In spite of his belief, the investigation found otherwise. For example, the aircraft’s weight and balance documents showed the APU was removed from the aircraft in December 2014. However, contrary to the requirements of FAA regulations, investigators found no notation in the aircraft maintenance record s to denote removal of the APU. Maintenance records from February 2015 indicated the APU was removed and replaced on February 9, but the company then failed to amend the aircraft’s weight and balance documents to reflect the added weight from the reinstall ation. Although not causal to the accident, I believe this poor attention to detail regarding maintenance records is reflective of how Execuflight operated.

The company had no formalized method for employees to report safety concerns. When asked if pilots had the authority to refuse a flight, the CEO insisted they could, yet there were no written policies or guidelines to support this. Written policies, procedures, and guidelines are only useful if they are followed, and the investigation of this tragedy f ound Execuflight wasn’t an organization that rigorously followed such rules. A few days prior to the accident, for example, Execuflight scheduled the first officer without the legally required rest period. The company did not follow their procedures for gr ading the accident pilots’ CRM tests. And, despite each of the accident pilots being terminated from their previous employers, Execuflight did not do due diligence to determine the specifics of why they were terminated.

Operational Factors Group Chairman’s Report, Attachment 2 – FXE Interview Transcripts.

NTSB Aircraft Accident Report The illusion of safety continued. E xecuflight’s sales agent told investigators, “I would say, yes, we’re are [ sic ] very top notch. ARGUS Gold, Wyvern Registered, very safe.” His reference to ARGUS and Wyvern was that they had standing with two industry auditing organizations (see Interview Summaries , p. 389) The pilots. There were multiple aspects of the accident flight that were substandard, and several of these were causal to the accident. The probable cause cited “the flight crew’s mismanagement of the approach and multiple deviations fro m company standard operating procedures.” Despite the entire approach being flown significantly below V speed, the crew did ref not correct this critically urgent situation. That failure ultimately led to the crash when they allowed the aircraft to stall.

But being slow on final approach was not the only aspect of the crew’s mismanagement of the flight. While descending below 10,000 feet, the crew failed to reduce speed to 250 knots, as required by regulations. They displayed a lax attitude toward conductin g the approach briefing and checklists. Required callouts were not made, the approach was flown at the improper configuration, and the crew failed to discontinue an unstabilized approach. And, although not directly a factor in this accident, the investigat ion found the captain had a history of failing to designate an alternate airport when weather conditions required one. When viewed collectively, these performance failures painted a picture of a crew destined not for Akron, but for tragedy.

The NTSB and industry sources have found that failure to comply with procedures has been a factor in the vast majority of crashes over the past several decades. For example, a 1994 NTSB safety study of 37 crew - involved air carrier accidents found that procedural errors , such as not making required callouts or failing to use appropriate checklists, were found in 29 of the 37 reviewed accidents. A Flight Safety Foundation study found that intentional crew non - compliance was a factor in 39.5% of the worldwide accidents th ey reviewed.

Analysis of Line Operations Safety Audit (LOSA) data from over 16,000 line flights revealed that flight crewmembers who intentionally deviated from SOPs made, on average, three times more errors, mismanaged more errors, and found themselves in more undesired aircraft situations, compared with those flight crewmembers that did not intentionally deviate from procedures.

Conversely, following procedures has a positive effect on safety. A Boeing study analyzed 138 airline accidents that claimed 5,686 lives over a ten - year period. The study analyzed factors that could have prevented each accident. The most highly ranked accident NTSB. (1994). Safety study: A re view of flightcrew - involved, major accidents of U.S. air carriers, 1978 through 1990. (NTSB Report No. NTSB/SS/94 - 01). Washington, DC: Author.

Khatwa, R. & Helmreich, R. (1999). Killers in aviation: FSF task force presents facts about approach - and - lan ding and controlled - flight - into - terrain accidents. Flight Safety Digest . November 1998 – February, 1999. 17(11 - 12). pp. 1 - 77. Retrieved from http://flightsafety.org/fsd/fsd_nov - feb99.pdf NTSB Aircraft Accident Report prevention strategy was following procedures, which could have prevented 48 percent of the accidents.

Regulatory over sight. The Board found that contributing to the accident was “the Federal Aviation Administration’s insufficient oversight of [Execuflight’s] training program and flight operations.” Due to funding limitations, the FAA’s principal operations inspector (POI ) assigned to Execuflight never visited Execuflight’s training at Simuflite, and he was not aware that an internal Execuflight audit was one year overdue. Despite the deficiencies identified in this investigation, the POI told NTSB that Execuflight was a “ very good operator.” Once again, there was an illusion of safety.

Industry audits. Finally, I’m concerned that an organization that had so many safety - related issues could have an ARGUS Gold rating and be Wyvern Registered. Discriminating customers look t o, and trust, such “seals of approval” when selecting their air travel provider.

This is not the first time the NTSB has seen an organization pass an industry audit, only to find after an accident that there was an illusion of safety. In June 2007, a chart ered Cessna 550 operated by Marlin Air crashed into Lake Michigan, claiming the lives of all six onboard. NTSB found egregious safety violations and deficiencies, including falsified training records, along with serious financial issues with Marlin Air. NT SB also found FAA failed to detect these training irregularities. Marlin Air possessed an ARGUS Gold rating.

In another case, NTSB investigated a crash involving East Coast Jets at Owatonna, MN.

Issues similar to the Akron crash were found in that crash . The NTSB found that the captain of that flight “did not comply with well - designed procedures intended to minimize operational errors, including sterile cockpit adherence, and this atmosphere permitted inadequate briefing of the approach and monitoring of the current weather conditions, including the wind information on the cockpit instruments; inappropriate conversation; nonstandard terminology; and a lack of checklist discipline throughout the descent and approach phases of the flight.” And similarly, NT SB determined that the FAA POI assigned to East Coast Jets was not sufficiently aware of East Coast Jets’ training. At the time of the accident, East Costs Jets held an ARGUS platinum rating, the highest safety rating awarded to operators that successfully pass an ARGUS on - site safety audit.

Although not involving ARGUS, another case involved a Gulfstream G4 crash at Bedford, MA. The investigation found the crew habitually failed to comply with preflight checks, having not performed a complete flight cont rol check in 98 percent of the past 175 Weener, E. (1993, November). Accident prevention strategies . Paper presented at 46th Flight Safety Foundation / International Federation of Airworthiness International Air Safety Seminar, International Air Safety Seminar. Kuala Lampur, Malaysia.

5 Marlin Air Inc. Operational factors / human performance 14 - interview summaries, page 3. R etrie ved from http://dms.ntsb.gov/pubdms/search/document.cfm?docID=3045 00&docketID=44492&mkey=65921 NTSB. (2011). Aircraft accident report: Crash during attempted go - around after landing, East Coast Jets Flight 81, Hawker Beechcraft Corporation 125 - 800A, N818MV, Owatonna, Minnesota, July 31, 2008. (NTSB Report No.

NTSB/AAR/ 11 - 01). Washington, DC: Author.

NTSB. (2015). Aircraft accident report: Runway Overrun During Rejected Takeoff , Gulfstream Aerospace Corporation G - IV, N121JM , Bedford, Massachusetts , May 31, 2014 . (NTSB Report No. NTSB/AAR/15 - 01).

Washington, DC: Author.

NTSB Aircraft Accident Report flights. However, the organization had successfully undergone two IS - BAO audits and received glowing comments from the auditor about the quality of the organization.

I am very concerned these industry audits did not detect serious safety deficiencies.

Customers rely on them to make their travel choices, and when audits fail to detect the very things they are designed to catch, it further bolsters an illusion of safety.

NTSB Aircraft Accident Report

5 . Appendix es

Appendix A: Investigation The National Transportation Safety Board (NTSB) was initially notified of this accident on November 10, 2015 . An investigator - in - charge from the Central Regional Office and investigators from NTSB headquarters in Washington, DC, traveled to the accident scene. The team was accompanied by Vice Chairman Bella Dinh - Zarr.

Investigators or investigative groups from the following disciplines participated: Operations, Human Performance, Aircraft Performance, Medical, Aircraft Systems, Aircraft Structures, Aircraft Pow erplants, Maintenance Records, Air Traffic Control, Meteorology, and Cockpit Voice Recorder.

Parties to t he investigation were the Federal Aviation Administration, Execuflight, Text ron Aviation, Honeywell International, and the National Air Traffic Control lers Association.

NTSB Aircraft Accident Report

Appendix B : Cockpit Voice Recorder Transcript

The following is a t ranscript of a Fairchild GA - 100 tape cockpit voice recorder, serial number 00044, installed on an Execuflight British Aerospace HS 125 - 700A (N237WR), which crashed during a pproach at Akron Fulton International Airport (AKR) in Akron, Ohio.

LEGEND

CAM Cockpit area microphone voice or sound source HOT Flight crew audio panel voice or sound source RDO Radio transmissions from N237WR AC - 91S Radio transmissions from aircraft registration ending in 91S CTR - A Radio transmission from an undetermined center controller CTR - CLE Radio transmission from the Cleveland center controller CTR - INDY Radio transmission from the Indianapolis center controll er APR - AKR Radio transmission from the Akron approach controller Wx - LHQ Automated Weather Broadcast from Fairfield County Airport, Lancaster Ohio Wx - AKR Automated Weather Broadcast from Akron Fulton International Airport EGPWS Enhanced Ground Proximity War ning System - 1 Voice identified as the pilot - 2 Voice identified as the co - pilot - 3 Voice identified as a passenger - ? Voice unidentified * Unintelligible word # Expletive @ Non - pertinent word ( ) Questionable insertion [ ] Editorial insertion Note 1: Times are expressed in eastern standard time (EST).

Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed.

Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic represe ntation of the words as spoken.

Note 4: A non - pertinent word, where noted, refers to a word not directly related to the operation, control or condition of the aircraft.

NTSB Aircraft Accident Report CVR Quality Rating Scale The levels of recording quality are characterized by the fo llowing traits of the cockpit voice recorder information: Excellent Quality Virtually all of the crew conversations could be accurately and easily understood.

The transcript that was developed may indicate only one or two words that were not intelligib le. Any loss in the transcript is usually attributed to simultaneous cockpit/radio transmissions that obscure each other.

Good Quality Most of the crew conversations could be accurately and easily understood. The transcript that was developed may indic ate several words or phrases that were not intelligible. Any loss in the transcript can be attributed to minor technical deficiencies or momentary dropouts in the recording system or to a large number of simultaneous cockpit/radio transmissions that obscu re each other.

Fair Quality The majority of the crew conversations were intelligible. The transcript that was developed may indicate passages where conversations were unintelligible or fragmented. This type of recording is usually caused by cockpit noise that obscures portions of the voice signals or by a minor electrical or mechanical failure of the CVR system that distorts or obscures the audio information.

Poor Quality Extraordinary means had to be used to make some of the crew conversations int elligible. The transcript that was developed may indicate fragmented phrases and conversations and may indicate extensive passages where conversations were missing or unintelligible. This type of recording is usually caused by a combination of a high coc kpit noise level with a low voice signal (poor signal - to - noise ratio) or by a mechanical or electrical failure of the CVR system that severely distorts or obscures the audio information.

Unusable Crew conversations may be discerned, but neither ordinary nor extraordinary means made it possible to develop a meaningful transcript of the conversations.

This type of recording is usually caused by an almost total mechanical or electrical failure of the CVR system.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:2 0 : 52 EST START OF RECORDING START OF TRANSCRIPT 14:20:54.5 HOT - ?

***.

14:21:01.0 HOT - ? ***.

14:21:07.6 HOT - 1 ***.

14:21:09.4 HOT - 2 ***.

14:21:14.7 HOT - 2 I - I (was) sayin' this it is going to be direct HUUVR and then direct destination. right?

14:21:19.2 HOT - 1 he doesn't want us to do the rest of the - ehh ***.

14:21:25.2 HOT - 2 one (nine) thousand. ***.

14:21:34.7 HOT - ?

***.

14:21:51.9 HOT - 1 well (so you're) climbing with V - S?

14:21:55.0 HOT - ( 2 ) I don't know. I was asking.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:21:56.0 HOT - 1 you have no **.

14:21:57.6 HOT - 2 right now I. I (fix) it.

14:21:58.6 HOT - 1 ***.

14:22:00.6 HOT - 2 which one?

14:22:01.7 HOT - 1 whatever make you feel good. I mean you want to keep climbing with fifteen hundred feet per minute or two hundred and fifty knots.

14:22:04.6 HOT - 2 **.

14:22:07.1 CTR - A Zipline fifteen twenty six contact Indy center one two four point four five. goodday.

14:22:12.7 RDO - 1 twenty four (forty) five Zipline fifteen twenty six.

14:22:44.7 HOT - 2 we're gonna lev -- (yeah) we're gonna level off now so I'm not worried about that.

14:22:49.4 HOT - ( 2 ) you're going to do. capture.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:22:53.3 HOT - 1 ***.

14:22:55.9 HOT - ?

***.

14:22:58.5 HOT - 2 unless you follow it all the time.

14:23:00.8 HOT - 1 ** I understand what you're saying but I don't want to (ah) follow it.

14:23:03.4 HOT - 1 looks like its going to do it whatever it wants to do.

14:23:06.4 HOT - ? ***.

14:23:09.6 RDO - 1 Center good morning Zipline fifteen twenty six with you out of sixteen thousand three hundred ah for one (seven) thousand.

14:23:16.0 CTR - INDY Zipline fifteen twenty six Indy Center. Columbus altimeter three zero zero three.

14:23:21.3 RDO - 1 three zero zero three. ***.

14:23:27.0 HOT - 1 yeah * must. ***. you know. **. like.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:23:32.1 HOT - ? I know. ** too.

14:24:24.3 HOT - 1 you can speed it up. a little bit.

14:24:27.5 HOT - ? ***.

14:24:35.1 HOT - ?

***.

14:24:37.4 CTR - INDY ** my frequency one two four point four five.

14:24:38.0 HOT - ?

***.

14:24:44.7 RDO - 1 one two four forty five Zipline fifteen twenty six.

14:24:48.1 CTR - INDY Zipline fifteen twenty six say again.

14:24:51.5 RDO - 1 and ah I thought you were talking to me. *. I'll - I'll stay with you one ***.

14:24:55.3 CTR - INDY Zipline fifteen twenty six (thank you).

14:25:01.5 HOT - ?

***.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:25:14.4 HOT - 2 that's another thing I don't under -- I don't understand. we have all these fuel flow indications. but we don't have like a either a fuel pressure or something. * extra (assurances) fuel is actually going **.

14:25:32.8 HOT - 1 **.

14:25:34.2 HOT - 2 ** fuel pressure. will be. will be. *.

14:25:41.2 HOT - 1 yeah. * 14:25:43.8 HOT - 2 yeah. *.

14:25:54.1 HOT - 1 * eight hundred. (just) a fuel pressure.

14:25:55.5 HOT - 2 eight hundred probably. but here you - you know.

14:25:59.5 HOT - 2 the only thing that you know that the engine is running. so you know that you are good. (otherwise).

14:26:01.4 HOT - 1 [chuckle] right.

14:26:06.0 HOT - 1 (here) you have radio number one.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:26:08.5 HOT - 2 number one is min e.

14:26:09.0 Wx - LHQ visibility one zero. sky condition overcast one thousand one hundred. temperature zero niner Celsius . dewpoint zero seven Celsius . altimeter three zero zero four. remarks.

density altitude three hundred. Fairfield County airport Lancaster Ohio. automated weather observation one niner two six zulu. wind two niner zero at zero seven. visibility one zero. sky condition broken one thous and one hundred.

overcast one thousand eight hundred. temperature zero niner Celsius . dewpoint zero -- .

14:26:56.1 HOT - 1 we got ah....we got ah. broken one thousand one hundred.

overcast one thousand eight hundred. visibility more than ten miles. (kil ometers) I'm sorry.

14:27:11.7 HOT - ?

so we got go out **.

14:27:14.1 HOT - 2 ** do me a favor. put (on) the flight plan the point from the localizer.

14:27:19.0 HOT - 2 so we're going to fly it ah eventually hopefully (navigation).

14:27:27.8 HOT - 2 ** two thousand six hundred. ***. I'll let you brief it to me. **.

14:27:56.0 HOT - ? ***.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:28:11.8 HOT - 1 okay. we got the weather. overcast so we (gonna be) runway twenty -- 14:28:17.2 HOT - 2 (breaking out).

14:28:19.2 Wx - LHQ -- information one niner two seven zulu. wind two niner zero at seven. visibility one zero. sky cond -- 14:28:23.6 HOT - ? **.

14:28:27.9 HOT - (1) localizer runway two **.

14:28:32.3 HOT - 1 (that's what the) briefing (is).

14:28:37.7 HOT - 1 twenty six eighty two.

14:28:43.1 HOT - ?

***.

14:28:46.5 HOT - 2 so we were listening at ah -- 14:28:48.5 HOT - 1 we were listening ***.

14:28:53.3 HOT - 1 (there) is only one runway we (should) use.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:28:55.0 HOT - 2 yeah.

14:28:55.5 HOT - 2 I would say localizer by the winds that they have on the forecast it would be runway two. the localizer.

14:29:03.4 HOT - 1 why what's the localizer. one one ten?

14:29:09.1 HOT - 2 one one zero decimal niner.

14:29:12.7 HOT - 1 final course? final course?

14:29:18.7 HOT - 1 (is a).

14:29:19.4 HOT - 2 ***.

14:29:20.9 HOT - 1 two...forty...nine.

14:29:30.2 CTR - INDY Zipline fifteen twenty six cross HUUVR niner thousand.

Columbus altimeter three zero zero six.

14:29:36.0 RDO - 1 HUUVR at niner thousand Zipline fifteen twenty six.

14:29:39.1 HOT - 1 HUUVR at (nine thousand) * we are fifty miles out.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:29:44.9 HOT - 2 fifty miles to HUUVR and we are doing ah three hundred. ah five miles per minute.

14:29:51.3 HOT - 1 if it -- 14:29:51.5 HOT - 2 four minutes we should lose how much?

14:29:55.3 HOT - 1 ** at this point. we wanted to cross at (nine) thousand.

14:29:58.8 HOT - 2 (nine) thousand feet.

14:30:00.1 HOT - 1 yeah.

14:30:00.5 HOT - 1 you know what we can (start shallow).

14:30:03.0 HOT - 2 yeah. (we'll) start shallow. and put it on the (right). *.

14:30:10.2 HOT - 1 then remember. you're not going anywhere.

14:30:14.7 HOT - ? (nine) thousand. right?

14:30:18.5 HOT - 1 now ** whatever he wants to do **.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:30:24.3 HOT - ? ** press ** look ***.

14:30:32.9 HOT - ?

***.

14:30:46.8 HOT - ? *.

14:30:50.0 HOT - ?

*** gotta be.

14:30:55.5 HOT - ? ***.

14:31:03.3 HOT - ?

twenty miles. HUUVR twenty miles. ***.

14:31:13.1 HOT - ? ***.

14:31:17.0 HOT - 1 oh yeah. we're ***.

14:31:25.5 HOT - ? ** you're right ***.

14:31:41.9 HOT - 1 so we're going to have a layover here for like three hours *.

14:32:17.6 CTR - INDY Zipline fifteen twenty six contact Cleveland Center one three four point niner.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:32:22.5 RDO - 1 three four point nine Zipline fifteen twenty six. bye - bye.

14:32:31.0 RDO - 1 Cleveland Center good morning. Zipline fifteen twenty six with you one four thousand down to nine thousand.

14:32:36.7 CTR - CLE Zipline fifteen twenty six. Cleveland Center. Akron - Canton altimeter two niner niner five.

14:32:42.1 RDO - 1 niner niner five. **.

14:32:44.6 HOT - 1 (one) (nine) ***.

14:32:54.0 HOT - 2 okay so we have the localizer two in there (right?).

14:32:57.3 HOT - 2 I mean ah localizer two five. alright.

14:33:00.8 HOT - 2 *** we got the inbound. (how's it gonna be). three thousand...

14:33:07.4 HOT - 1 (three thousand).

14:33:08.3 HOT - 2 ...then can go to twenty three.

14:33:09.1 HOT - 2 now we got to change the places. * because ** direct **.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:33:16.5 CAM - 3 you guys know where you're goin'? you know where you're goin'?

14:33:20.5 HOT - 1 [laughter] 14:33:21.5 HOT - 2 actually. (I'll let) you be here for a couple of minutes. then you gotta go. because there gonna be weather. we cannot be distracted.

14:33:24.9 CAM - 3 okay.(you guys). I'm just joking. we're going into Akron - Fulton right?

14:33:31.8 HOT - (1or2) yep.

14:33:32.9 CAM - 3 **.

14:33:38.8 HOT - 2 okay. so we go down twenty three. then down to (what's the minimums?).

14:33:44.8 HOT - 1 four seventy three.

14:33:46.7 HOT - 2 four seventy three.

14:33:48.3 HOT - 1 (let's) do four eighty.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:33:52.7 HOT - 2 then we're gonna put the missed approach.

14:33:55.1 HOT - 1 what's the missed approach?

14:34:02.0 HOT - ? three thousand.

14:34:03.7 HOT - ?

okay what we do.

14:34:05.4 HOT - 1 climb to three thousand. via two forty three ** outbound ***.

14:34:22.8 HOT - 2 alright. so we gotta. we're gonna have to. ***. all we have to do is a go to the eh the missed approach. okay so we go three thousand runway heading *** the radial. ***.

14:34:38.3 HOT - 1 *** (RITZS) intersection. *** 14:34:41.5 HOT - ?

roger.

14:34:46.4 HOT - 2 we gotta get that radial. to go to *** -- 14:34:48.5 HOT - 1 I'll do that.

14:34:49.3 HOT - 1 * that's good. that's good.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:34:51.8 HOT - (1) that's exactly what we want to do.

14:34:54.2 HOT - 2 so two forty nine. three thousand feet. good. then you. then we put the - the eh V - O - R.

14:35:07.2 HOT - 1 **.

14:35:09.8 HOT - 2 **.

14:35:12.0 HOT - 1 **.

14:35:14.5 HOT - 2 **.

14:35:15.9 HOT - (1) * radial there*.

14:35:17.0 HOT - 2 go inbound on the - on the three twenty two. which is ah ***.

14:35:28.3 HOT - 2 okay?

14:35:29.8 HOT - ? okay I think. **.

14:35:31.0 HOT - ?

**.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:35:32.7 HOT - 1 (ATIS is)?

14:35:34.2 HOT - 2 I gotta. I gotta get **.

14:35:36.1 HOT [unintelligible discussion between 1 and 2] 14:35:59.6 HOT - 2 the overcast is ah is ah ground. from the ground the overcast.

right? so.

14:36:06.2 HOT - 2 ** from the overcast ah the (minima) is four seventy five. so we should come out at eight hundred. and we should have four hundred feet to go to it.

14:36:17.0 HOT - ? (the overcast is ground).

14:36:19.0 HOT - ?

(from the ground).

14:36:19.7 HOT - ? **.

14:36:20.3 HOT - ?

yeah.

14:36:21.6 HOT - 1 no **. the report.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:36:24.1 HOT - 2 no no no.

14:36:26.9 HOT - 2 *** the minima for this approach fifteen twenty.

14:36:33.3 HOT - 2 (unless. unless you're high. fifteen sixty).

14:36:36.2 HOT - 2 which is ground. where is the ground. five oh one right? *.

14:36:42.8 HOT - 2 now. if the overcast is eight hundred. *.

14:36:43.9 HOT - 1 (one thousand to the level).

14:36:45.9 HOT - 2 if we had *** overcast. ***. then we have three hundred feet to minimums.

14:36:51.9 HOT - ? **.

14:37:02.6 HOT - ?

** you know what I'm sayin'.

14:37:04.9 HOT - ? yeah. *. *. *.

14:37:06.7 HOT - 1 the report is. is. ***.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:37:09.7 HOT - 2 yeah I understand. but we can shoot it. we can shoot because the overcast * reporting * eight hundred. ***.

14:37:19.2 HOT [unintelligible dialogue between the pilots] 14:37:32.7 HOT - 2 the cloud base is from the ground. from the ground do we get minimums for us.

14:37:37.1 HOT - 1 still. we get ***.

14:37:38.2 HOT - 2 **.

14:37:39.2 Wx - AKR -- three seven zulu. wind two four zero at zero eight. visibility one and one (half). sky condition overcast -- [interrupted by pilot 2 responding to radio call] -- Celsius . dewpoint zero niner Celsius altimeter two niner niner -- [interrupted by pilot 2 resp onding to radio call] -- density altitude niner hundred.

Akron Fulton International Airport automated weather observation -- [interrupted by pilot 2 responding to radio call] - - two four zero at zero eight. visibility one and one half mist.

sky condition -- [interrupted by pilot 2 responding to radio call] -- altimeter two niner niner five. remarks -- [interrupted by pilot 2 responding to radio call] -- density altitude niner hundred. Akron Fulton International Airport automated weather observation one niner thr ee eight zulu. wind two four zero at zero eight. visibility one and one half mist. sky condition overcast six hundred broken. temperature one one Celsius . dewpoint zero niner Celsius . altimeter two niner niner five. remar -- NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:37:44.6 CTR - CLE Z ipline fifteen twenty six contact Akron - Canton approach one one eight point six.

14:37:49.1 RDO - 2 one one eight point six ahhh Zipline fifteen twenty six.

14:37:59.2 RDO - 2 and Akron Approach ah good afternoon. Zipline fifteen twenty one. we are ah (ten) thousand over HUUVR.

14:38:08.9 APR - AKR sorry. I was (on the landline). * that Zipline fifteen twenty six calling?

14:38:12.9 RDO - 2 ** over HUUVR nine thousand feet. we are inbound at this time.

14:38:17.4 APR - AKR Zipline fifteen twenty six fly heading zero six five vector localizer two five final approach course (vector). advise (when you have) weather.

14:38:24. 9 RDO - 2 * heading zero six five for now. we are in the process of copying the weather. ah maintaining nine thousand. Zipline one five two six.

14:38:32.6 APR - AKR Zipline one five two six descend at pilot's discretion.

maintain fife thousand.

14:38:37.3 RDO - 2 P - D five thousand. ah fifteen twenty six. roger.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:38:41.6 Wx - AKR -- density altitude niner hundred. Akron Fulton International Airport automated weather observation one niner three eight zulu. wind two four zero at zero eight. visibility one and one (half) mist. sky condition overcast six hundred *.

temperature one one Celsius . dewpoint zero niner Celsius .

altimeter two niner niner five.

14:38:44.6 CAM [sound of decreased background noise, similar to power reduction] 14:38:48.8 HOT - ? ***.

14:39:17.0 HOT - 1 we got. two four zero at eight.

14:39:20.5 HOT - 2 (that's what I got).

14:39:22.4 HOT - 1 one and half mile visibility. overcast at six hundred.

14:39:26.9 HOT - 2 and ah what visibility does this approach want?

14:39:31.8 HOT - 1 one and three quarter. ah. (us). one and half.

14:39:35.9 HOT - 2 * one and. one mile.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:39:38.8 HOT - 1 okay. one and.

14:39:39.8 HOT - 2 one and a half.

14:39:40.7 HOT - 1 alright we are visibility we got it.

14:39:42.7 HOT - 2 and.

14:39:44.4 HOT - 1 yeah but overcast six hundred.

14:39:46.6 HOT - 2 like I say *** from the ground. and the and the minima is five hundred ground.

14:39:52.6 HOT - 1 okay. listen. focus. ** we are going down to five thousand right.

14:39:57.2 HOT - 2 yeah.

14:40:01.5 HOT - 2 no. let it - let it go.

14:40:03.6 HOT - 1 it will be doing whatever they want to do. to support speed or.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:40:08.0 HOT - 2 yah. yah. I'm going I'm gonna drive it with the. let me show you now. *.

14:40:13.6 HOT - 1 I know what you mean. and now you were doing it to ***. we discussed everything ***.

14:40:25.0 HOT - 1 did you do my approach (brief). *** (we gotta go somewhere else right). ***.

14:40:34.2 HOT - 1 * if you say that. I might be wrong. I'm not sure.

14:40:37.9 HOT - 2 ***.

14:40:39.9 HOT - 1 I might be wrong. but.

14:40:41.1 HOT - 2 (** shoot it).

14:40:44.8 HOT - 2 (okay). we're almost there.

14:40:49.2 HOT - 1 ***.

14:40:51.9 HOT - 2 ***.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:41:00.1 HOT - 1 **. R - NAV or.

14:41:03.0 APR - AKR * nine one (sierra charlie) ** two two zero. intercept the localizer.

14:41:03.7 HOT - 2 localizer. he said we going to do a get. expect the localizer.

14:41:08.8 HOT - 2 ***. the minima is five hundred and ten. *** minima.

14:41:14.8 HOT - 1 localizer?

14:41:15.7 HOT - 2 yeah.

14:41:16.0 HOT - 1 (good).

14:41:19.4 HOT - 1 four eighty. four eighty.

14:41:21.6 HOT - ?

* four eighty. four eighty.

14:41:24.9 HOT - 2 four seventy three.

14:41:26.5 HOT - 2 sure?

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:41:28.4 HOT - 2 ** four eighty.

14:41:30.4 HOT - ?

[grunt].

14:41:32.0 HOT - 1 Akron.

14:41:35.7 HOT - 1 Akron.

14:41:36.8 HOT - 2 yeah. after Akron.

14:41:38.6 HOT - 1 fifteen hundred.

14:41:41.1 HOT - 2 before Akron we can do maximum twenty three. right? before Akron.

14:41:44.9 HOT - ? **.

14:41:45.1 HOT - 1 ten miles before. (should) * go down to...

14:41:48.6 HOT - 1 ...(we) go down to two thousand three hundred.

14:41:53.2 HOT - 2 **. we got. we got. ah direct to (here). **. so. he's gonna vector us. you want to put on the eh the final course.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:41:58.2 HOT - 1 **.

14:42:04.3 HOT - 2 (three) (six) (two).

14:42:05.6 HOT - 1 three six two.

14:42:07.0 HOT - 2 what is the name of the (Akron)?

14:42:09.2 HOT - 1 * Akron.

14:42:12.8 HOT - ?

(uhk) [may be saying AKRON NDB identifier, AK] 14:42:13.8 HOT - 1 put in on ** top **.

14:42:21.1 APR - AKR * niner one sierra. four miles from the outer marker.

maintain (two) thousand till established on the localizer.

cleared for the localizer two five approach into Akron Fulton.

14:42:27.7 AC - 91S (maintain three thousand till established localize r. ** approach.)

14:42:37.6 HOT - 1 put it on. **.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:42:48.4 HOT - 1 put (nine) miles.

14:42:51.6 HOT - ?

**. yeah this one.

14:42:56.2 HOT - 1 *. (ack) [emphasized] (lohm) [emphasized]. ** Akron N - D - B.

14:43:04.8 HOT - 1 which is this.

14:43:07.1 HOT - 1 and then the airport which is kilo ***.

14:43:18.7 HOT - 2 we could have put in the box Akron itself.

14:43:26.7 HOT - ? yeah. *.

14:43:31.5 HOT - 1 he's gonna take us around?

14:43:32.9 HOT - 2 yeah. obviously. yeah.

14:43:38.6 HOT - 2 I see what you did. you put the N - D - B instead * of putting * name * itself.

14:43:44.5 HOT - 1 oh I got'chya.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:43:44.6 APR - AKR * niner one sierra changed to advisory frequency approved ***.

14:43:46.7 HOT - 2 see what I'm saying.

14:43:48.1 HOT - 2 the same point though?

14:43:49.2 HOT - 1 uh. (yeah). that's right.

14:43:50.2 HOT - 2 the same point. right. yeah.

14:43:52.1 AC - 91S ** change to advisory. ** (we'll cancel as soon as we can).

14:43:52.2 HOT - 1 the same one.

14:43:59.8 APR - AKR (Zipline) * fifteen twenty six reduce speed to two zero zero.

descend and maintain four thousand.

14:43:59.8 HOT - 1 N - D - B.

14:44:01.0 HOT - 2 no. you're gonna need to go to yes. (right there).

14:44:02.9 HOT - 2 direct - a to.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:44:09.6 APR - AKR Zipline fifteen twenty six reduce speed to two zero zero.

descend (now) and maintain four thousand.

14:44:15.5 CAM [sound of decreased background sound, similar to power reduction] 14:44:15.6 RDO - 1 two zero zero the speed. and four thousand. Zipline fifteen twenty six.

14:44:19.8 HOT - 1 we're two zero zero.

14:44:21.4 HOT - 2 and then we go down to.

14:44:22.2 HOT - 1 doing whatever you want to do.

14:44:23.5 HOT - 2 I touch.

14:44:24.1 HOT - 1 right now. the ***. we have no **.

14:44:51.1 CAM - ?

select the altitude.

14:44:55.0 CAM [sound of two thumps] NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:45:05.5 CAM [splice in CVR tape] 14:45:16.3 CAM [sound of ratcheting, similar to rotary dial] 14:45:24.2 APR - AKR Zipline fifteen twenty six turn left ah heading three five zero.

14:45:28.2 RDO - 1 left heading three five zero Zipline fifteen twenty six **.

14:45:31.7 HOT - 2 three five zero (and) **.

14:45:37.0 CAM [cough] 14:45:38.5 HOT - 2 now he's gonna bring (us) (abeam). the localizer.

14:45:45.8 HOT - ?

**.

14:45:47.0 HOT - 1 [throat clearing] 14:45:55.3 HOT - 2 *** M - S - L.

14:46:04.8 HOT - 1 okay.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:46:05.5 APR - AKR ** Zipline fifteen twenty six we do have another aircraft that's inbound to the airport (that) is slower than you. fly heading of three six zero and reduce speed one seven zero. ** descend and maintain three thousand.

14:46:16.9 CAM [sound of decreas ed noise, similar to power reduction] 14:46:18.5 RDO - 1 down to three thousand. one seven zero on the speed and three five zero Zipline fifteen twenty six.

14:46:25.5 HOT - 1 three six zero on the speed. one seven zero -- 14:46:28.7 HOT - 2 three six zero on the speed [ spoken loudly ].

14:46:30.3 HOT - 1 ah. * three [chuckle] six. three six zero on the heading. one seven zero on the speed.

14:46:34.4 HOT - 2 three six zero confirmed down to three thousand.

14:46:36.7 HOT - 1 down to three thousand. he wants one seven zero knots.

14:47:09.1 APR - AKR Zipline fifteen twenty six turn left heading two eight zero.

intercept the localizer to Akron Fulton.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:47:15.5 RDO - 1 two seven ze -- eh two eight zero. intercept the localizer.

Zipline fifteen twenty six.

14:47:22.4 HOT - 1 alright.

14:47:23.9 HOT - 2 where are we.

14:47:25.5 HOT - 1 ***.

14:47:26.9 HOT - 2 this is the distance from Akron?

14:47:30.0 HOT - 1 ***.

14:47:31.6 HOT - 2 ***.

14:47:38.7 HOT - 1 you got your localizer?

14:47:39.6 HOT - 2 two eight zero (heading).

14:47:40.6 HOT - 1 (go) two eight zero.

14:47:41.5 HOT - 1 but you're never gonna capture.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:47:43.0 HOT - ? you know.

14:47:47.4 HOT - 2 let's see if she's gonna do it though. I will. I till try to. drag every (thing).

14:47:53.9 HOT - 2 let's see what she does. okay. just keep me updated on the distance.

14:48:01.6 HOT - 2 ***.

14:48:08.0 HOT - 1 radar altimeter alive.

14:48:10.4 HOT - 1 we are like seven miles from Akron ap -- 14:48:14.1 CAM - ? [raspy, female voice, unintelligible in background.]

14:48:14.3 CAM - 1 oh we got. we got. we got nine degrees pitch up. *. [ said with emphasis ] 14:48:17.4 APR - AKR Zipline fifteen twenty six * on the approach ***. expect no delay.

14:48:21.6 CAM [sound of increased noise, similar to power increase] NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:48:25.7 CAM [sound of thump] 14:48:27.0 CAM [sound of increased noise, similar to landing gear extension] 14:48:27.2 CAM [after this point until the end of the recording, the increased noise from the gear obscures portions of the recording; most notably, ATC communicatio ns.]

14:48:28.2 RDO - 1 okay we'll continue the approach. ah. ***. Zipline fifteen twenty six.

14:48:33.9 HOT - 1 did you hear what he say? there is an airplane on the approach. (he is) slower than us. he hasn't cancelled. we don't know if he's on the ground. [ said with emphasis ] 14:48:34.2 CAM [sound of click] 14:48:37.7 HOT - 2 **.

14:48:41.1 HOT - 2 ***.

14:48:42.9 HOT - 1 you can't. [ emphasized] 14:48:44.1 HOT - 2 why. [loud] NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:48:44.6 HOT - 1 you need to (look). you need to. I mean we were - we were flying like (one thirty nine). nine degrees pitch up.

14:48:50.1 HOT - 2 yeah.

14:48:51.6 HOT - 2 ** speed is one seventy **.

14:48:55.7 HOT - 1 ** (flaps) ** I know but **.

14:49:09.0 HOT - 2 we should (uh) -- 14:49:13.6 CAM [sound of decreased background noise, similar to decrease in airspeed] 14:49:17.7 HOT - ? ***.

14:49:20.4 HOT - 1 *** you're going one forty *** -- .

14:49:22.9 APR - AKR Zipline fifteen twenty six I got the cancellation here. and you're ah four miles from the outer compass locator.

maintain three thousand until established on the localizer *.

cleared localizer two five approach *.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:49:33.3 RDO - 1 (cleared to) localizer two five. (maintain **). Zipline one five two six. **.

14:49:40.4 APR - AKR roger.

14:49:41.3 HOT - 1 look you're going one twenty. you can't keep decreasing your speed ** -- 14:49:42.7 APR - AKR [unintelligible] 14:49:45.3 HOT - 2 no. one tw -- . how do you get one twenty? [ said with emphasis ] 14:49:47.1 HOT - 2 ** one twenty five **.

14:49:48.9 HOT - 1 v - ref plus (fifteen).

14:49:50.9 HOT - 2 (which) is the approach speed.

14:49:53.0 HOT - 1 you've (still) got. flaps to go. * 14:49:54.9 HOT - 2 and when you put them -- NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:49:56.1 HOT - 1 that's what I'm saying. if you keep decreasing your speed -- .

14:50:00.3 HOT - 2 but why?

14:50:02.1 HOT - 1 * because we gonna stall. I don't want to sta -- 14:50:03.9 HOT - 2 how do you -- 14:50:05.1 HOT - 1 (but in) I - M - C.

14:50:12.5 HOT - 1 alright. after Akron. we are down to.

14:50:16.2 HOT - 2 minimums.

14:50:17.0 HOT - 1 fifteen hundred.

14:50:21.0 HOT - ? *** -- .

14:50:21.6 APR - AKR Zipline fifteen twenty six change to advisory frequency approved. report cancelling I - F - R in the air on this frequency. or on the ground via remote.

14:50:29.7 RDO - 1 (we'll change on to the advisory frequency) ***.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:50:35.8 HOT - ? ***.

14:50:39.8 RDO - 1 Akron. Akron traffic. ah Zipline fifteen twenty (six) is a Hawker jet. on the localizer two five we are (Akron position).

**.

14:50:50.8 HOT - ? (one) mile.

14:50:53.9 AC - 91S hey guys. ah we just landed on the loc. and uh broke out right at minimums (right at a) mile.

14:50:58.9 RDO - 1 appreciate it.

14:51:00.9 HOT - 2 (four) miles. full flaps.

14:51:06.7 HOT - 1 gear down. before landing. three lights. one. and.

14:51:13.6 CAM [sound of decreased background sound, similar to power reduction] 14:51:14.4 HOT - 1 (are) we going down to.

14:51:15.7 HOT - 2 (to).

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:51:17.1 HOT - 1 *.

14:51:17.4 CAM [sound of thunk] 14:51:18.2 HOT - 2 **.

14:51:25.4 HOT - 1 *** speed ***.

14:51:31.3 HOT - 2 alright we go to minimums (@).

14:51:32.9 HOT - 1 alright.

14:51:36.3 HOT - 2 can you check. can you check (if I got) (everything). ( ignition ).

14:51:39.6 HOT - 1 everything is (all set).

14:51:41.2 HOT - 1 standby. yaw damper. autopilot. (eh).

14:51:43.9 HOT - 1 main air valves.

14:51:44.7 HOT - 2 *.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:51:45.2 HOT - 1 I'll take care of them.

14:51:46.7 HOT - 2 (alright).

14:51:49.4 HOT - 1 v - ref. (localizer).

14:51:56.6 HOT - 1 on localizer. you're diving. you're diving. don't dive. two thousand feet per minute buddy... [ said with emphasis ] 14:52:01.8 HOT - 2 yeah.

14:52:02.5 HOT - 1 ...two thousand feet per minu -- don't go two thousand feet per minute. [ said with emphasis ] 14:52:05.1 HOT - 1 you're ** (me there).

14:52:06.4 HOT - 1 oh don't.

14:52:07.1 HOT - 2 yeah.

14:52:07.3 HOT - 1 don't go two thousand feet per minute.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:52:10.2 HOT - 1 when you are fifteen hundred feet above the ground. or minimums.

14:52:15.2 CAM [sound of cyclical sound, similar to windshield wipers ; continues until end of recording ] 14:52:17.0 HOT - 1 ground.

14:52:20.5 HOT - 1 keep going.

14:52:22.1 HOT - 1 one point one is for the missed approach.

14:52:27.3 HOT - 1 okay level off guy. [spoken rapidly] 14:52:27.4 CAM [sound of rattle, similar to stick shaker] 14:52:28.3 HOT - 2 got it.

14:52:30.1 CAM [sound of rattle, similar to stick shaker] 14:52:31.3 HOT - 1 oh #. (focus). [spoken loudly, rapidly] 14:52:32.8 GPWS pull up.

NTSB Aircraft Accident Report TIME and TIME and SOURCE INTRA - AIRCRAFT CONTENT SOURCE AIR - GROUND COMMUNICATION CONTENT 14:52:33.6 HOT - 1andor2 oh oh oh oh. [ said with emphasis ] 14:52:34.7 HOT [sound of thunk, similar to impact] 14:52:35.0 HOT [sound of squeal , similar to tape recording electronic artifact] END OF TRANSCRIPT END OF RECORDING 14:5 2 : 35.4 EST NTSB Aircraft Accident Report

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