Accident at Akron, Ohio, 10 Nov 2015 (HS-125)

Accident narrative

On November 10, 2015, about 1453 eastern standard time, Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), departed controlled flight during a nonprecision localizer approach to runway 25 at Akron Fulton International Airport in Akron, Ohio. The airplane impacted a four-unit apartment building and was destroyed by impact forces and a postcrash fire. The captain, first officer, and seven passengers died. No one on the ground was injured.

**The flight and crew** The airplane was operated by Execuflight as an on-demand charter flight under 14 Code of Federal Regulations Part 135. The accident flight was the second leg of the day on the second day of a planned two-day, seven-leg trip. The flight departed from Dayton-Wright Brothers Airport in Dayton, Ohio, about 1413, destined for Akron.

The captain, 40, had about 6,170 hours of total flight time, including about 1,020 hours in the HS-125. The first officer, 50, had about 4,382 hours of total flight time, with about 482 hours in the HS-125. Both pilots were hired by Execuflight in June 2015.

**Preflight preparation** Before departure, the captain filed an instrument flight rules flight plan. The weather forecast available at the time of planning called for a 700-foot ceiling and 4 miles visibility at the estimated time of arrival, with an AIRMET calling for ceilings less than 1,000 feet and visibility below 3 miles. Based on these forecasts, federal regulations required an alternate airport to be filed, but the captain did not list one.

The flight crew calculated the airplane's weight and balance using a software program. The investigation found that an incorrect basic empty weight of 13,815 lbs was entered as a default instead of the airplane's actual basic operating weight of 14,276.92 lbs. Additionally, the crew used standard weights of 200 lbs per passenger and 250 lbs for baggage instead of actual weights. This resulted in an underestimate of the airplane's takeoff weight. The Board estimated the actual takeoff weight was 23,786 lbs, which exceeded the flight's landing-limited maximum takeoff weight of 23,500 lbs. The Board noted this exceedance likely did not adversely affect the airplane's performance, but concluded that the multiple deviations concerning weight and balance represented a pattern of routine disregard for standard operating procedures (SOPs).

**The approach** The airplane was equipped with a cockpit voice recorder (CVR), but was not equipped with a flight data recorder, nor was it required to be. The CVR indicated that the first officer was the pilot flying and the captain was the pilot monitoring. This was contrary to Execuflight's informal practice of the captain acting as the pilot flying on flights carrying revenue passengers.

About 1426, the flight crew began preparing for the approach by attempting to obtain the automated weather at Akron. They incorrectly tuned the radio and received the weather for Fairfield County Airport, which indicated a visibility of 10 miles and a ceiling of 1,100 feet.

At 1427:27, the first officer asked the captain to brief the approach to him. The captain agreed, contrary to company SOPs which specified that the pilot flying was to brief the approach. The ensuing briefing was unstructured and incomplete. The first officer made statements indicating he was referencing the area navigation (RNAV) approach chart rather than the localizer 25 approach chart, and he incorrectly referred to the ceiling height as the controlling weather minimum rather than the visibility.

At 1436:40, radar recorded the flight descending through 10,000 feet mean sea level (msl) at an estimated airspeed of 298 knots, violating the regulatory maximum speed of 250 knots below 10,000 feet.

At 1437:39, the CVR recorded the correct automated weather at Akron, reporting an overcast ceiling of 600 feet and a visibility of 1 1/2 miles. The captain and first officer discussed the visibility and determined they had the required minimum to start the approach. The crew never completed the approach briefing or the Approach checklist.

About 1444, the approach controller instructed the flight to reduce speed to 200 knots and descend to 4,000 feet. Two minutes later, the controller notified the flight that they were following a slower airplane and issued a further speed reduction to 170 knots and a descent to 3,000 feet. To reduce speed, the first officer began configuring the airplane for landing. At 1448:14, the captain noted that the airplane had a nine-degree pitch up attitude. The CVR recorded the sound of the landing gear extending. Neither crewmember made the required callouts for configuration changes.

At 1449:22, the controller cleared the flight for the localizer 25 approach and instructed the flight to maintain 3,000 feet until established on the localizer. Radar data indicated the airplane was already established on the localizer and could have descended to the final approach fix (FAF) minimum crossing altitude of 2,300 feet. However, the first officer did not initiate a descent, and the airplane remained level at 3,000 feet.

As the first officer continued to slow the airplane, the captain warned him about the decaying speed. At 1449:41, the captain said, "look you're going one twenty. you can't keep decreasing your speed." The first officer responded, "how do you get one twenty?" The captain replied, "because we gonna stall." The Board concluded that the first officer's lack of awareness should have prompted the captain to take control of the airplane or call for a missed approach, but he did not do so.

At 1450:53, a pilot of the preceding slower airplane transmitted on the local advisory frequency that they had landed and broke out of the clouds right at minimums at one mile.

**The descent and crash** At 1451:00, the first officer requested "full flaps" (45 degrees). This was contrary to Execuflight's nonprecision approach profile, which required the airplane to be flown at 25 degrees of flaps until after descending to the minimum descent altitude (MDA) and landing was assured. The captain did not question the decision and failed to make the required flap callouts. The captain began to recite the Landing checklist, but the crew never completed it.

At 1451:13, the first officer reduced power, and the airplane began to descend. The airplane crossed the FAF at an altitude of about 2,700 feet, which was 400 feet higher than the published minimum crossing altitude, and at an airspeed of 109 knots. Because the airplane was high, it was out of position to use a normal descent rate. The descent rate rapidly increased to 2,000 feet per minute. At 1451:56, the captain said, "on localizer. you're diving. you're diving. don't dive. two thousand feet per minute buddy." The captain did not attempt to take control. As the descent continued, the captain failed to make required callouts regarding approaching the MDA.

Radar data indicated the airplane reached the MDA of 1,540 feet msl (473 feet above the touchdown zone elevation) about 1452:13. The airspeed was about 113 knots, 11 knots below the minimum required airspeed, and the descent rate was about 830 feet per minute. The airplane was improperly configured with 45-degree flaps. The Board concluded that the approach was unstabilized and the captain should have initiated a missed approach. Instead, at 1452:17, the captain stated, "ground," and then, "keep going." The first officer continued the descent.

At 1452:27, about 14 seconds after descending below the MDA, the captain instructed the first officer to level off. The CVR immediately recorded the sound of the stick shaker, followed by a ground proximity warning system "pull up" alert. About seven seconds after the instruction to level off, the CVR recorded the first sounds of impact.

**What the investigation found** Examination of the accident site indicated the airplane struck tree branches and power lines before impacting the apartment building. The landing gear were down and locked, and the flaps were extended to about 45 degrees. Both engines were operating during the impact sequence. The angle-of-attack indicator on the captain's instrument panel was found with its needle in the red (stall) band.

Simulator testing showed that maintaining level flight at flaps 45 required a fuel flow of 1,150 lbs per hour per engine, significantly more than the 800 lbs per hour per engine that Execuflight pilots were trained to apply to level the airplane at the MDA at flaps 25. The Board concluded that 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-degree flap setting, resulting in an aerodynamic stall.

**Organizational factors and oversight** The Board evaluated the flight crew's background and training. Execuflight's review of the pilots' previous employment records was found to be cursory. The first officer's records detailed significant training difficulties at his previous employer, which had terminated him for unsatisfactory work performance. A check airman's letter noted his simulator performance was "ridiculously weak." The captain had been terminated from his previous employer for failing to attend scheduled training. Execuflight's president hired both pilots based on recommendations and single flights, and the company did not contact the previous employers to discuss these issues.

The investigation found that the flight crew received inadequate crew resource management (CRM) training. The pilots' CRM tests, which required an 80% uncorrected score to pass, were improperly graded. The captain scored 40% but was marked 100%; the first officer scored 70% but was marked 80%. Execuflight's chief pilot initialed both tests. Areas where the crewmembers were deficient—including responsibilities of the pilot-in-command and aeronautical decision-making—were the same areas where errors occurred during the flight.

The Board determined that Execuflight had a casual attitude toward compliance with standards, illustrating a disregard for operational safety. The company lacked a safety management system (SMS) and a flight data monitoring (FDM) program, which could have identified the flight crew's routine disregard for SOPs, such as the captain's history of failing to file alternate airports.

The Board also evaluated the pilots for fatigue. The first officer had flown an overnight trip ending on November 8 with only 7 hours 45 minutes of rest, violating the 10-hour regulatory requirement. The Board concluded the first officer was likely experiencing fatigue due to circadian disruption and improper crew scheduling, though the extent to which fatigue contributed to his performance could not be determined. The captain's degraded performance was consistent with the effects of fatigue, but insufficient evidence existed about his normal sleep needs to determine if he was fatigued.

The Federal Aviation Administration's (FAA) principal operations inspector (POI) assigned to Execuflight oversaw 16 certificates and characterized his workload as "very busy." He relied primarily on line checks flown locally and did not conduct en route inspections. He had never visited the training center to observe Execuflight simulator training and was unaware that an audit of the company's training program was a year overdue. The Board concluded the FAA failed to provide adequate oversight of Execuflight's pilot training, maintenance, and operations.

**Operational issues and CVR maintenance** The Board reviewed the nonprecision approach procedures taught to Hawker 700-series pilots. The step-down technique required descending to the MDA at flaps 25, leveling off, and selecting flaps 45 when "landing assured." Because many nonprecision approaches have MDAs below 1,000 feet, this technique required configuration changes at low altitudes, contrary to FAA stabilized approach crite