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    AIR CRASH INVESTIGATIONS FLIGHT CREW’S MISMANAGEMENT OF THE APPROACH-The Crash of British Aerospace Flight 1526
    AIR CRASH INVESTIGATIONS FLIGHT CREW’S MISMANAGEMENT OF THE APPROACH-The Crash of British Aerospace Flight 1526
    AIR CRASH INVESTIGATIONS FLIGHT CREW’S MISMANAGEMENT OF THE APPROACH-The Crash of British Aerospace Flight 1526
    Ebook229 pages2 hours

    AIR CRASH INVESTIGATIONS FLIGHT CREW’S MISMANAGEMENT OF THE APPROACH-The Crash of British Aerospace Flight 1526

    By Lulu.com

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    On November 10, 2015, a British Aerospace HS 125-700A, N237WR, operated by Execuflight, crashed during a nonprecision localizer approach to runway 25 at Akron Fulton International Airport and impacted a four-unit apartment building in Akron, Ohio. This report discusses the November 10, 2015, accident in which a British Aerospace HS 125-700A, N237WR, registered to Rais Group International NC LLC and operated by Execuflight, departed controlled flight while on a nonprecision localizer approach to runway 25 at Akron Fulton International Airport and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. Safety issues discussed in this report relate to a lack of a requirement for flight data monitoring programs for 14 Code of Federal Regulations (CFR) Part 135 operators, a lack of a requirement for safety management system programs for 14 CFR Part 135 operators, a lack of a nonprecision approach procedure for Hawker 700- and 800-series airplanes that meets stabilized approach criteria and defines “landing assured,” a lack of a requirement for flight crew training on the continuous descent final approach technique, inaccuracy of data entered into weight-and-balance software, inadequate Federal Aviation Administration (FAA) surveillance of Part 135 operators, and inadequate cockpit voice recorder maintenance procedures. Safety recommendations are addressed to the FAA, Textron Aviation, and Hawker 700- and 800-series training centers.
    LanguageEnglish
    PublisherLulu.com
    Release dateOct 3, 2023
    ISBN9781446716977
    AIR CRASH INVESTIGATIONS FLIGHT CREW’S MISMANAGEMENT OF THE APPROACH-The Crash of British Aerospace Flight 1526

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      AIR CRASH INVESTIGATIONS FLIGHT CREW’S MISMANAGEMENT OF THE APPROACH-The Crash of British Aerospace Flight 1526 - Lulu.com

      CHAPTER 1: FACTUAL INFORMATION

      History of the Flight

      On November 10, 2015, about 1453 eastern standard time (EST), Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), N237WR, departed controlled flight while on a nonprecision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio.¹ The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed from Dayton-Wright Brothers Airport (MGY), Dayton, Ohio, about 1413 and was destined for AKR.

      The accident flight was the crewmembers’ second flight of the day and occurred on the second day of a planned 2-day, 7-leg trip with the same crew and passengers on board for each leg. The trip began on November 9, 2015, about 0650 from the company’s base of operations at Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. After stops in St. Paul, Minnesota; Moline, Illinois; and St. Louis, Missouri, the first day of the trip ended about 1955 at Cincinnati Municipal Airport-Lunken Field (LUK), Cincinnati, Ohio. The second day of the trip was planned for flights from LUK to MGY, then to AKR, and finally a return to FXE.

      On the day of the accident, the first flight of the day departed LUK about 1103 and arrived at MGY about 1133. While at MGY, the captain filed an IFR flight plan for flight 1526 to AKR, planning a 34-minute flight at a cruise altitude of 17,000 ft above mean sea level (msl), with a cruise speed of 382 knots and a departure time of 1330. According to the fueling service at MGY, the pilots requested that both wing tanks be filled to their capacity, and the airplane was fueled with 410 gallons (2,788 lbs) of Jet A fuel about 1145.

      About 1349, the captain sent a doors closed text message from his cell phone to company management, and one of the pilots then contacted flight service to obtain their IFR clearance to AKR. Air traffic control (ATC) issued the flight an IFR clearance to AKR with a hold for release awaiting another inbound IFR aircraft into MGY. About 1409, the flight was given its release, and about 1413, the flight departed runway 20 at MGY.

      About 1416, the flight contacted the Indianapolis Air Route Traffic Control Center (ARTCC), and the controller cleared the flight to climb to 17,000 ft msl and, 2 minutes later, cleared it to AKR via direct to the HUUVR intersection and then direct to the airport.² A review of cockpit voice recorder (CVR) audio, which began at 1420:52, indicated that the first officer was acting as the pilot flying (PF) and the captain was acting as the pilot monitoring (PM).³

      About 1426, the flight crew began preparing for the approach into AKR by attempting to obtain the weather at AKR via the automated surface observing system (ASOS) broadcast. The did not correctly tune the radio and received the 1426 automated weather observation for Fairfield County Airport, Lancaster, Ohio, located about 108 miles (mi) southwest of AKR, which indicated a visibility of 10 mi, a broken ceiling of 1,100 ft above ground level (agl), and an overcast cloud layer at 1,800 ft agl.⁴ At 1427:27.8, the first officer said, I’ll let you brief it to me, and the flight crew then began discussing the localizer 25 approach at AKR (see figure 1, which shows a copy of the approach chart used by the flight crew).

      At 1429:30.2, the controller cleared the flight to cross the HUUVR intersection at 9,000 ft msl, and at 1432:17.6, the flight was issued a frequency change from Indianapolis ARTCC to Cleveland ARTCC. After checking in with Cleveland ARTCC, the flight crew returned to their discussion of the localizer 25 approach, which was interrupted at 1433:16.5 when a passenger came forward from the cabin and spoke to the crew. About this time, the airplane was descending through 13,500 ft msl, and the first officer told the passenger that he could stay a couple of minutes but then had to leave because we cannot be distracted. 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 a final approach fix (FAF) minimum crossing altitude of 2,300 ft msl, a minimum descent altitude (MDA) of 1,540 ft msl, and the height of the MDA above the runway 25 touchdown zone elevation (TDZE) was 473 ft.

      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, and at 1436:36.2, he said, which is ground. where is the ground. five oh one right? The approach chart for the AKR area navigation (RNAV) GPS approach to runway 25 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.⁶ At 1436:40, radar data recorded the flight descending through 10,000 ft msl with an estimated airspeed of about 298 knots.⁷

      The flight crew continued to discuss the overcast height above the ground. 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.⁸ At 1437:32.7, he stated, the cloud base is from the ground. From the ground do we get minimums for us.

      At 1437:39.2, the CVR recorded the 1438 automated weather at AKR, which was reporting an overcast ceiling of 600 ft agl, a visibility of 1 1/2 mi in mist, and wind from 240° at 8 knots. At 1437:44.6, the Cleveland ARTCC controller instructed the flight to change frequencies to Akron approach. The first officer checked in with Akron approach and reported that the flight was level at 9,000

      Figure 1. Instrument approach chart for the localizer approach to runway 25 at Akron Fulton International Airport at the time of the accident.

      At 1437:39.2, the CVR recorded the 1438 automated weather at AKR, which was reporting an overcast ceiling of 600 ft agl, a visibility of 1 1/2 mi in mist, and wind from 240° at 8 knots. At 1437:44.6, the Cleveland ARTCC controller instructed the flight to change frequencies to Akron approach. The first officer checked in with Akron approach and reported that the flight was level at 9,000 ft msl over HUUVR. The approach controller gave the flight a 65° heading, told the pilots to expect the localizer 25 approach at AKR, and asked the pilots to advise when they had the weather at AKR. The first officer replied, we are in the process of copying the weather. The controller then cleared the flight to descend at the pilots’ discretion to 5,000 ft msl.

      At 1439:22.4, the captain repeated the current AKR weather conditions, stating, one and half mile visibility. overcast at six hundred. The captain and first officer then discussed the visibility, and, at 1439:40.7, the captain commented, alright we are visibility we got it.⁹

      At 1440:25.0, the captain said, did you do my approach (brief). *** (we gotta go somewhere else right). ***, and at 1440:34.2, the captain continued saying, * if you say that. I might be wrong. I’m not sure. The first officer’s response was unintelligible.

      At 1441:08.8, the first officer said, ***. the minima is five hundred and ten. ***minima, followed by the captain questioning localizer? At 1441:19.4, the captain said, four eighty. Four eighty. At 1441:24.9, the first officer said, four seventy three, which was the height above the TDZE of the MDA for the localizer 25 approach.

      At 1443:59.8, the approach controller instructed the flight to reduce speed to 200 knots and descend to 4,000 ft msl. About 2 minutes later, at 1446:05.5, the approach controller notified the flight 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.¹⁰ At 1447:09.1, the approach controller gave the flight a 280° heading and instructions to join the localizer course for runway 25. At 1447:40, the airplane reached an altitude of about 3,000 ft msl and leveled off. At 1447:47.4, the first officer said, …I will…try to. drag every (thing), indicating he planned to begin configuring the airplane for landing by extending the flaps and landing gear.

      At 1448:14.3, the captain said, with emphasis, oh we got. we got. we got nine degrees pitch up. *, indicating that he noticed the first officer flying with a high pitch attitude. At 1448:21.6, the CVR recorded increased noise consistent with a power increase, and at 1448:27.0, the CVR recorded the sound of a thump followed by increased noise similar to landing gear extension.¹¹ 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. At 1448:44.6, the captain again commented on the pitch attitude, saying, you need to (look). you need to. I mean we were-were flying like (one thirty nine). nine degrees pitch up. The National Transportation Safety Board’s (NTSB) radar performance study determined that, between 1448:30 and 1449:30, the pitch of the airplane increased from about 5° to 12° nose up,and the airspeed slowed from about 150 to 125 knots.¹²

      Figure 2. Profile view of the airplane's approach to runway 25 at Akron Fulton International Airport based on radar data.

      Note: The 3° glideslope [GS] depicted is for reference only; the localizer approach to runway 25 does not include vertical guidance.

      At 1449:22.9, when the flight was about 4 nautical miles (nm) from the FAF for the localizer 25 approach at AKR, the approach controller advised that the pilots of the slower airplane ahead had cancelled their IFR flight plan and cleared the Execuflight airplane for the localizer approach. The captain acknowledged the clearance and advised that they were established on the localizer. Once established on the localizer approach, the flight was no longer required to remain at the previous ATC-assigned altitude of 3,000 ft msl and could descend to the FAF minimum crossing altitude of 2,300 ft msl. Radar data indicated that the airplane remained level at 3,000 ft msl for about 2 minutes before it began to descend (see figure 2, which shows the airplane’s descent path).

      At 1449.41.3, the captain said, look you’re going one twenty. you can’t keep decreasing your speed**. The first officer responded, no. one tw--. how do you get one twenty? At 1449:56.1, the captain said, that’s what I’m saying. if you keep decreasing your speed--, and the first officer interrupted, but why? to which the captain replied, *because we gonna stall. I don’t want to sta--.

      At 1450:21.6, the approach controller instructed the flight to change to the local advisory frequency, and, at 1450:39.8, the captain made a position report on the local advisory frequency. At 1450:53.9, one of the pilots of the preceding slower airplane that had just landed at AKR said, hey guys. ah we just landed on the loc. and uh broke out right at minimums (right at a) mile, and the captain responded, appreciate it.

      At 1451:00.9, the first officer requested full flaps (45° flaps). The captain began to recite the Landing checklist at 1451:06.7, stating, gear down. before landing. three lights. one. and. At 1451:08, the airplane’s airspeed, which had stabilized about 130 knots, began to decrease. At 1451:13.6, the first officer reduced the power, and the airplane, which had been level about 3,000 ft msl, began to descend. At 1451:31.3, the first officer said, alright we go to minimums, indicating that the airplane was crossing the FAF and could now descend to the

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