Crash of a BAe 125-700A in Akron: 9 killed

Date & Time: Nov 10, 2015 at 1453 LT
Type of aircraft:
Operator:
Registration:
N237WR
Survivors:
No
Site:
Schedule:
Dayton – Akron
MSN:
257072
YOM:
1979
Flight number:
EFT1526
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
6170
Captain / Total hours on type:
1020.00
Copilot / Total flying hours:
4382
Copilot / Total hours on type:
482
Aircraft flight hours:
14948
Aircraft flight cycles:
11075
Circumstances:
The aircraft departed controlled flight while on a non precision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and post crash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Dayton-Wright Brothers Airport, Dayton, Ohio, about 1413 and was destined for AKR. Contrary to Execuflight’s informal practice of the captain acting as pilot flying on flights carrying revenue passengers, the first officer was the pilot flying, and the captain was the pilot monitoring. While en route, the flight crew began preparing for the approach into AKR. Although company standard operating procedures (SOPs) specified that the pilot flying was to brief the approach, the captain agreed to the first officer’s request that the captain brief the approach. The ensuing approach briefing was unstructured, inconsistent, and incomplete, and the approach checklist was not completed. As a result, the captain and first officer did not have a shared understanding of how the approach was to be conducted. As the airplane neared AKR, the approach controller instructed the flight to reduce speed because it was following a slower airplane on the approach. To reduce speed, the first officer began configuring the airplane for landing, lowering the landing gear and likely extending the flaps to 25° (the airplane was not equipped with a flight data recorder, nor was it required to be). When the flight was about 4 nautical miles from the final approach fix (FAF), the approach controller cleared the flight for the localizer 25 approach and instructed the flight to maintain 3,000 ft mean sea level (msl) until established on the localizer. The airplane was already established on the localizer when the approach clearance was issued and could 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 airplane from about 150 to 125 knots, the captain made several comments about the decaying speed, which was well below the proper approach speed with 25° flaps of 144 knots. The first officer’s speed reduction placed the airplane in danger of an aerodynamic stall if the speed continued to decay, but the first officer apparently did not realize it. The first officer’s lack of awareness and his difficulty flying the airplane to standards should have prompted the captain to take control of the airplane or call for a missed approach, but he did not do so. Before the airplane reached the FAF, the first officer requested 45° flaps and reduced power, and the airplane began to descend. The first officer’s use of flaps 45° was contrary to Execuflight’s Hawker 700A non precision approach profile, which required the airplane to be flown at flaps 25° until after descending to the minimum descent altitude (MDA) and landing was assured; however, the captain did not question the first officer’s decision to conduct the approach with flaps 45°. The airplane crossed the FAF at an altitude of about 2,700 ft msl, which was 400 ft higher than the published minimum crossing altitude of 2,300 ft msl. Because the airplane was high on the approach, it was out of position to use a normal descent rate of 1,000 feet per minute (fpm) to the MDA. The airplane’s rate of descent quickly increased to 2,000 fpm, likely due to the first officer attempting to salvage the approach by increasing the rate of descent, exacerbated by the increased drag resulting from the improper flaps 45° configuration. The captain instructed the first officer not to descend so rapidly but did not 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 captain did not make the required callouts regarding approaching and reaching the MDA, and the first officer did not arrest the descent at the MDA. When the airplane reached the MDA, which was about 500 ft above the touchdown zone elevation, the point at which Execuflight’s procedures dictated that the approach must be stabilized, the airspeed was 11 knots below the minimum required airspeed of 124 knots, and the airplane was improperly configured with 45° flaps. The captain should have determined that the approach was unstabilized and initiated a missed approach, but he did not do so. About 14 seconds after the airplane descended below the MDA, the captain instructed the first officer to level off. As a result of the increased drag due to the improper flaps 45° configuration and the low airspeed, the airplane entered a stalled condition when the first officer attempted to arrest the descent. About 7 seconds after the captain’s instruction to level off, the cockpit voice recorder (CVR) recorded the first sounds of impact.
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 environment, and an aerodynamic stall. Contributing to the accident were Execuflight’s casual attitude toward compliance with standards; its inadequate hiring, training, and operational oversight of the flight crew; the company’s lack of a formal safety program; and the Federal Aviation Administration’s insufficient oversight of the company’s training program and flight operations.
Final Report:

Crash of a Socata TBM-850 in Salem

Date & Time: May 19, 2011 at 0843 LT
Type of aircraft:
Operator:
Registration:
N1UL
Flight Type:
Survivors:
Yes
Schedule:
Valparaiso - Salem
MSN:
564
YOM:
2010
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
932
Captain / Total hours on type:
76.00
Aircraft flight hours:
187
Circumstances:
The pilot reported that he flew an instrument approach and was clear of clouds about 650 feet above ground level when he proceeded visually to the airport. About 1/2 mile from the runway, he thought the airplane was too high, but a few seconds later the airplane felt like it had an excessive rate of descent. His attempts to arrest the rate of descent were unsuccessful, and the left main landing gear struck the ground about 120 feet prior to the runway threshold. The recorded data downloaded from the airplane's non-volatile memory showed that the airplane's airspeed varied from about 71 - 81 knots indicated airspeed (IAS) during the 10 seconds prior to ground impact. The data also indicated that there was about a 3 - 5 knot tailwind during the final landing approach. The airplane's stall speed with the airplane in the landing configuration with landing flaps was 64 knots IAS at maximum gross weight. The pilot reported that there was no mechanical malfunction or system failure of the airplane.
Probable cause:
The pilot's failure to maintain a stabilized glide path which resulted in the airplane touching down short of the runway.
Final Report:

Crash of a Rockwell Aero Commander 500 in Columbus

Date & Time: Dec 27, 2010 at 2246 LT
Operator:
Registration:
N888CA
Flight Type:
Survivors:
Yes
Schedule:
Jeffersonville – Columbus
MSN:
500B-1318-127
YOM:
1963
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5700
Captain / Total hours on type:
3525.00
Circumstances:
Prior to the flight, the pilot preflighted the airplane and recalled observing the fuel gauge indicating full; however, he did not visually check the fuel tanks. The airplane departed and the en route portion of the flight was uneventful. During the downwind leg of the circling approach, the engines began to surge and the pilot added full power and turned on the fuel boost pumps. While abeam the approach end of the runway on the downwind leg, the engines again started to surge and subsequently lost power. He executed a forced landing and the airplane impacted terrain short of the runway. A postaccident examination by Federal Aviation Administration inspectors revealed the fuselage was buckled in several areas, and the left wing was crushed and bent upward. The fuel tanks were intact and approximately one cup of fuel was drained from the single fuel sump. Fueling records indicated the airplane was fueled 3 days prior to the accident with 135 gallons of fuel or approximately 4 hours of operational time. Flight records indicated the airplane had flown approximately 4 hours since refueling when the engines lost power.
Probable cause:
The pilot’s improper fuel management which resulted in a loss of engine power due to fuel exhaustion.
Final Report:

Crash of a Mitsubishi MU-2B-60 Marquise in Elyria: 4 killed

Date & Time: Jan 18, 2010 at 1405 LT
Type of aircraft:
Registration:
N80HH
Flight Type:
Survivors:
No
Schedule:
Gainesville - Elyria
MSN:
732
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2010
Captain / Total hours on type:
1250.00
Copilot / Total flying hours:
190
Aircraft flight hours:
6799
Circumstances:
On his first Instrument Landing System (ILS) approach, the pilot initially flew through the localizer course. The pilot then reestablished the airplane on the final approach course, but the airplane’s altitude at the decision height was about 500 feet too high. He executed a missed approach and received radar vectors for another approach. The airplane was flying inbound on the second ILS approach when a witness reported that he saw the airplane about 150 feet above the ground in about a 60-degree nose-low attitude with about an 80-degree right bank angle. The initial ground impact point was about 2,150 feet west of the runway threshold and about 720 feet north (left) of the extended centerline. The cloud tops were about 3,000 feet with light rime or mixed icing. The flap jack screws and flap indicator were found in the 5-degree flap position. The inspection of the airplane revealed no preimpact anomalies to the airframe, engines, or propellers. A radar study performed on the flight indicated that the calibrated airspeed was about 130 knots on the final approach, but subsequently decreased to about 95–100 knots during the 20-second period prior to loss of radar contact. According to the airplane’s flight manual, the wings-level power-off stall speed at the accident aircraft’s weight is about 91 knots. The ILS approach flight profile indicates that 20 degrees of flaps should be used at the glide slope intercept while maintaining 120 knots minimum airspeed. At least 20 degrees of flaps should be maintained until touchdown. The “No Flap” or “5 Degrees Flap Landing” flight profile indicates that the NO FLAP Vref airspeed is 115 knots calibrated airspeed minimum.
Probable cause:
The pilot's failure to maintain adequate airspeed during the instrument approach, which resulted in an aerodynamic stall and impact with terrain.
Final Report:

Crash of a Convair CV-580 in Columbus: 3 killed

Date & Time: Sep 1, 2008 at 1206 LT
Type of aircraft:
Operator:
Registration:
N587X
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Columbus - Mansfield
MSN:
361
YOM:
1956
Flight number:
HMA587
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
16087
Copilot / Total flying hours:
19285
Aircraft flight hours:
71965
Circumstances:
The accident flight was the first flight following maintenance that included flight control cable rigging. The flight was also intended to provide cockpit familiarization for the first officer and the pilot observer, and as a training flight for the first officer. About one minute after takeoff, the first officer contacted the tower and stated that they needed to return to land. The airplane impacted a cornfield about one mile southwest of the approach end of the runway, and 2 minutes 40 seconds after the initiation of the takeoff roll. The cockpit voice recorder (CVR) indicated that, during the flight, neither the captain nor the first officer called for the landing gear to be raised, the flaps to be retracted, or the power levers to be reduced from full power. From the time the first officer called "rotate" until the impact, the captain repeated the word "pull" about 27 times. When the observer pilot asked, "Come back on the trim?" the captain responded, "There's nothing anymore on the trim." The inspection of the airplane revealed that the elevator trim cables were rigged improperly, which resulted in the trim cables being reversed. As a result, when the pilot applied nose-up trim, the elevator trim system actually applied nose-down trim. The flight crew was briefed on the maintenance work that had been performed on the airplane; therefore, when the captain’s nose-up trim inputs were affecting his ability to control the airplane, at a minimum, he should have stopped making additional inputs and returned the airplane to the configuration it was in before the problem worsened. An examination of the maintenance instruction cards used to conduct the last inspection revealed that the inspector's block on numerous checks were not signed off by the Required Inspection Item (RII) inspector. The RII inspector did not sign the item that stated: "Connect elevator servo trim tab cables and rig in accordance with Allison Convair [maintenance manual]...” The item had been signed off by the mechanic, but not by the RII inspector. The card also contained a NOTE, which stated in bold type, "A complete inspection of all elevator controls must be accomplished and signed off by an RII qualified inspector and a logbook entry made to this effect." The RII inspector block was not signed off.
Probable cause:
The improper (reverse) rigging of the elevator trim cables by company maintenance personnel, and their subsequent failure to discover the misrigging during required post-maintenance checks. Contributing to the accident was the captain’s inadequate post-maintenance preflight check and the flight crew’s improper response to the trim problem.
Final Report:

Crash of a Cessna 340 in Port Clinton: 4 killed

Date & Time: Jan 12, 2008 at 1239 LT
Type of aircraft:
Operator:
Registration:
N2637Y
Flight Type:
Survivors:
No
Schedule:
Mansfield - Port Clinton
MSN:
340-0013
YOM:
1971
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1160
Captain / Total hours on type:
13.00
Aircraft flight hours:
6820
Circumstances:
During the landing approach, a witness saw the twin-engine airplane slow and stall. The airplane crashed short of the runway, in a residential backyard. An airport manager flew with the pilot 8 days before the accident. The manager reported that during his flight the pilot flew the approach and landing with the aural stall warning horn activated. The manager advised the pilot of the aural warning, however no corrective action was taken by the pilot during that flight. An on-scene investigation revealed no preimpact mechanical anomalies. The pilot had about 12.6 hours of flight time in the accident airplane, of which 7.7 hours were dual instruction. Due to the lack of any mechanical problems with the airplane, the pilot's minimal experience in twin-engine airplanes, and his history of flying the airplane too slow, it is probable that he allowed the airspeed to decay below a safe speed, and inadvertently stalled it.
Probable cause:
The pilot's failure to maintain sufficient airspeed to avoid a stall during the landing approach.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Columbus: 2 killed

Date & Time: Dec 5, 2007 at 0651 LT
Type of aircraft:
Operator:
Registration:
N28MG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Columbus - Buffalo
MSN:
208B-0732
YOM:
1999
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1310
Captain / Total hours on type:
200.00
Aircraft flight hours:
9936
Aircraft flight cycles:
9033
Circumstances:
The cargo flight was departing on its fourth flight leg of a five-leg flight in night instrument conditions, which included a surface observation of light snow and a broken ceiling at 500 feet above ground level (agl). One pilot who departed just prior to the accident flight indicated that moderate snow was falling and that he entered the clouds about 200 feet agl. The accident airplane's wings and tail were de-iced prior to departure. Radar track data indicated the accident flight was about 45 seconds in duration. An aircraft performance radar study indicated that the airplane reached an altitude of about 1,130 feet mean sea level (msl), or about 400 feet above ground level, about 114 knots with a left bank angle of about 29 degrees. The airplane descended and impacted the terrain at an airspeed of about 155 knots, a pitch angle of -16 degrees, a left roll angle of 22 degrees, and a descent rate of 4,600 feet per minute. The study indicated that the engine power produced by the airplane approximately matched the engine power values represented in the pilot's operating handbook. The study indicated that the required elevator deflections were within the available elevator deflection range, and that the center-of-gravity (CG) position did not adversely affect the controllability of the airplane. The study indicated that the load factor vectors, the forces felt by the pilot, could have produced the illusion of a climb, even when the airplane was in a descent. The inspection of the airframe and engine revealed no anomalies that would have precluded normal operation.
Probable cause:
The pilot's failure to maintain aircraft control and collision avoidance with terrain due to spatial disorientation. Contributing to the accident were the low cloud ceiling and night conditions.
Final Report:

Crash of a Learjet 35A in Columbus

Date & Time: Jan 10, 2007 at 0330 LT
Type of aircraft:
Operator:
Registration:
N40AN
Flight Type:
Survivors:
Yes
Schedule:
Jacksonville - Columbus
MSN:
35-271
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6400
Captain / Total hours on type:
1700.00
Copilot / Total flying hours:
3500
Copilot / Total hours on type:
600
Aircraft flight hours:
20332
Circumstances:
The airplane was substantially damaged during an in-flight recovery after the captain attempted an intentional aileron roll maneuver during cruise flight and lost control. The cargo flight was being operated at night under the provisions of 14 CFR Part 135 at the time of the accident. The captain reported the airplane was "functioning normally" prior to the intentional aileron roll maneuver. The captain stated that the "intentional roll maneuver got out of control" while descending through flight level 200. The captain reported that the airplane "over sped" and experienced "excessive G-loads" during the subsequent recovery. The copilot
reported that the roll maneuver initiated by the captain resulted in a "nose-down unusual attitude" and a "high speed dive." Inspection of the airplane showed substantial damage to the left wing and elevator assembly.
Probable cause:
The pilot's failure to maintain aircraft control during an inflight maneuver which resulted in the design stress limits of the airplane being exceeded. A factor was the excessive airspeed
encountered during recovery.
Final Report:

Crash of a Dassault Falcon 20D-5 in Lorain

Date & Time: Sep 1, 2005 at 1950 LT
Type of aircraft:
Operator:
Registration:
N821AA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lorain - Saint Louis
MSN:
203
YOM:
1970
Flight number:
JUS821
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4444
Captain / Total hours on type:
639.00
Copilot / Total flying hours:
2172
Copilot / Total hours on type:
193
Aircraft flight hours:
16970
Circumstances:
The small, twin-engine business jet was about 15 feet above the runway on takeoff, when a flock of birds from both sides of the runway flew up in front of the airplane. The number two engine "surged," and "loud reports" were heard before the copilot noted a complete loss of power on the number two engine instruments. The airplane climbed for about 10 seconds, before the copilot observed the gas producer (N1) gauge on the number one engine decay through 50 percent. The stall warning horn sounded, and the pilot adjusted the flight controls for landing. The airplane contacted the runway with the landing gear retracted, overran the runway, struck a fence, crossed a road, and came to rest in a cornfield about 1,000 feet beyond the initial point of ground contact. Post accident examination of both engines revealed evidence and damage consistent with multiple bird ingestion.
Probable cause:
The ingestion of multiple birds in each engine at takeoff, which resulted in a complete loss of engine power.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Rittman

Date & Time: Jun 4, 2005 at 1830 LT
Operator:
Registration:
N3434
Flight Type:
Survivors:
Yes
Schedule:
Rittman - Rittman
MSN:
193
YOM:
1968
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10420
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
7400
Aircraft flight hours:
33058
Circumstances:
The purpose of the flight was for the second pilot to perform an evaluation of the first pilot, who was recently designated by the operator as a backup pilot. Following several successful flights with and without passengers, the pilots discussed single engine operations, and the first pilot reduced the right engine's power to flight idle and feathered the propeller. During the final leg of the approach to landing, the airplane crossed over a fence near the runway threshold, and the first pilot pitched the airplane downward. The nose landing gear contacted the runway "hard," and the airplane began to bounce. After several bounces, the first pilot elected to abort the landing, increased power on the left engine to "full." As the first pilot pitched the airplane upward, it yawed to the right, "stalled," and impacted the ground.
Probable cause:
The pilot's improper flare and recovery from a bounced landing, which resulted in a stall and subsequent impact with the ground.
Final Report: