CEN16MA036

NTSB accident investigation · British Aerospace HS 125 700A · Akron, OH · November 10, 2015

Accident · FatalClass 1 · MajorFinal report
Date
November 10, 2015, 14:52 local (19:52 UTC)
Place
Akron, OH
Injuries
9 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N237WRBritish Aerospace HS 125 700A
Defining event
Approach-IFR final approach: Aerodynamic stall/spin
Weather
Instrument (IMC) · Day
Status
Completed · report October 24, 2016
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Central Region
Parties
FAA AVP-100, Execuflight, Honeywell, Textron Aviation, National Air Traffic Controllers Association, FAA Cleveland FSDO
Safety recommendations
Yes
FAA report
20151110023649A
Case key
92314

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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.

Findings · 11

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedBritish Aerospace HS 125-700A: 1 caseAll aircraft: 809 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededBritish Aerospace HS 125-700A: 1 caseAll aircraft: 990 casesProbable cause
Safety programs: adequacy of safety programOrganizational issues › Support/oversight/monitoring · OperatorBritish Aerospace HS 125-700A: 1 caseAll aircraft: 24 casesProbable cause
Oversight: oversight of reg complianceOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBritish Aerospace HS 125-700A: 1 caseAll aircraft: 14 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBritish Aerospace HS 125-700A: 1 caseAll aircraft: 61 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-16/03. On November 10, 2015, about 1453 eastern standard time (EST), Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), N237WR, departed controlled flight while on a nonprecision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed from Dayton-Wright Brothers Airport (MGY), Dayton, Ohio, about 1413 and was destined for AKR.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-16/03. On November 10, 2015, about 1453 eastern standard time (EST), Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), N237WR, departed controlled flight while on a nonprecision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed from Dayton-Wright Brothers Airport (MGY), Dayton, Ohio, about 1413 and was destined for AKR.

Aircraft

Registration
N237WR
Reported as
British Aerospace HS 125 700A
Category
Airplane
Serial number
NA-0252
Built
1979
Airframe hours
14,875
Engines
Honeywell TFE731-3R-1H, 3,700 lbs thrust, turbo fanHoneywell TFE731-3DR-1H, 3,700 horsepower, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Execuflight, doing business as Execuflight Inc.
Registered owner
Rais Group International Nc LLC
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · August 12, 2015
Departed
MGY · Dayton, OH
Destination
AKR · Akron, OH
Flight plan
IFR
Airport
AKC · Akron Fullton Internatinonal, runway 25, 6,336 × 159 ft, asphalt
Equipment
Auto-pilot, Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Injuries
Fatal
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
August 6, 2015
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
6,170 total · 1,020 in this make and model · 3,414 as pilot in command · 118 in the last 90 days · 43 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
50
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Seat
Right
Toxicology
Performed
Flight hours
4,382 total · 482 in this make and model · 3,200 as pilot in command · 78 in the last 90 days · 38 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
240° at 8 knots
Visibility
1.5 statute miles
Lowest ceiling
600 ft overcast
Temperature
52 °F, dew point 48 °F
Altimeter
29.95 inHg
Observed at
AKR, 2 nm away

Docket · 63

The files NTSB released with the investigation on April 20, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 344 MB in all.

Cockpit voice recorder - group chairman's factual reportItem 1 · PDF · 49 pages · 607 KBOperations group chairman's factual reportItem 2 · PDF · 102 pages · 17 photos · 7.9 MBOperations attachment 1 a�� interview summariesItem 3 · PDF · 32 pages · 496 KBOperations attachment 2 a�� fxe interview transcriptsItem 4 · PDF · 466 pages · 973 KBOperations attachment 3 a�� witness statementsItem 5 · PDF · 7 pages · 1 photo · 766 KBOperations attachment 4 a�� flight crew informationItem 6 · PDF · 27 pages · 888 KBOperations attachment 5 a�� captain training recordsItem 7 · PDF · 31 pages · 145 MBOperations attachment 6 a�� first officer training recordsItem 8 · PDF · 23 pages · 56.8 MBOperations attachment 7 a�� CRM training resultsItem 9 · PDF · 6 pages · 3.4 MBOperations attachment 8 - captain previous employerItem 10 · PDF · 2 pages · 1.8 MBOperations attachment 9 - fo previous employerItem 11 · PDF · 8 pages · 723 KBOperations attachment 10 - skyking check airman interviewItem 12 · PDF · 3 pages · 171 KBOperations attachment 11 a�� trip kitItem 13 · PDF · 5 pages · 9.6 MBOperations attachment 12 a�� weight and balanceItem 14 · PDF · 13 pages · 4.3 MBOperations attachment 13 a�� mgy fueling recordsItem 15 · PDF · 8 pages · 520 KBOperations attachment 14 a�� chart informationItem 16 · PDF · 6 pages · 2.2 MBOperations attachment 15 a�� akr localizer DME testingItem 17 · PDF · 14 pages · 12.0 MBOperations attachment 16 a�� cae simulator testingItem 18 · PDF · 35 pages · 19 photos · 2.6 MBOperations attachment 17 a�� party formsItem 19 · PDF · 3 pages · 6.5 MBOperations attachment 18 a�� flight following textsItem 20 · PDF · 4 pages · 3 photos · 252 KBOperations attachment 19 a�� execuflight sopsItem 21 · PDF · 4 pages · 440 KBOperations attachment 20 a�� poi work planItem 22 · PDF · 7 pages · 124 KBOperations addendum 1 - fss transcriptItem 23 · PDF · 7 pages · 112 KBHuman performance factual reportItem 24 · PDF · 6 pages · 32 KBHuman performance factual - attachment 1Item 25 · PDF · 3 pages · 831 KBHuman performance factual - attachment 2Item 26 · PDF · 101 pages · 1.1 MBHuman performance factual - attachment 3Item 27 · PDF · 123 pages · 1.5 MBAirplane radar performance studyItem 28 · PDF · 12 pages · 4.5 MBAirplane radar performance study errataItem 29 · PDF · 3 pages · 37 KBStall speeds and AOAItem 30 · PDF · 1 page · 841 KBCockpit voice recorder maintenance history - specialist's factual reportItem 31 · PDF · 9 pages · 5 photos · 789 KBCockpit voice recorder maintenance history - attachment 1 - chief pilot interviewItem 32 · PDF · 6 pages · 1.1 MBCockpit voice recorder maintenance history - attachment 2 - FAA poi interviewItem 33 · PDF · 2 pages · 90 KBCockpit voice recorder - group chairman's sound spectrum studyItem 34 · PDF · 12 pages · 688 KBCockpit voice recorder - group chairman's sound spectrum study - attachment 1Item 35 · CSV · 4 KBStructure's group chairman's factual reportItem 36 · PDF · 14 pages · 13 photos · 6.3 MBPowerplants group chairman's factual reportItem 37 · PDF · 20 pages · 29 photos · 1.7 MBSystems group chairman's factual reportItem 38 · PDF · 22 pages · 13 photos · 5.6 MBSystems group chairman's factual report - attachment 1Item 39 · PDF · 7 pages · 20 photos · 1.4 MBMaintenance recordsItem 40 · PDF · 66 pages · 327 KBAir traffic control - ATC group factual reportItem 41 · PDF · 14 pages · 339 KBAir traffic control - akr airport diagramItem 42 · PDF · 1 page · 156 KBAir traffic control - standard operating procedures for akron approach controlItem 43 · PDF · 58 pages · 6.6 MBAir traffic control - flight progress stripItem 44 · PDF · 1 page · 54 KBAir traffic control - position logsItem 45 · PDF · 4 pages · 1.1 MBAir traffic control - facility accident-incident notification recordItem 46 · PDF · 1 page · 423 KBAir traffic control - aircraft accident-incident preliminary noticeItem 47 · PDF · 4 pages · 1.4 MBAir traffic control - radar data for EFT1526Item 48 · PDF · 5 pages · 19 KBAir traffic control - akr localizer runway 25 approach chartItem 49 · PDF · 1 page · 217 KBAir traffic control - daily record of operationsItem 50 · PDF · 1 page · 279 KBAir traffic control - accident packageItem 51 · PDF · 51 pages · 8.3 MBFss transcript eft 1526Item 52 · PDF · 6 pages · 30 KBMeteorology factualItem 53 · PDF · 37 pages · 2.7 MBNTSB medical factual reportItem 54 · PDF · 3 pages · 323 KBToxicology report - oscar chavez mosqueraItem 55 · PDF · 1 page · 69 KBToxicology report - renato marcheseItem 56 · PDF · 1 page · 71 KBNTSB party formsItem 57 · PDF · 13 pages · 27.7 MBSecurity video of accidentItem 58 · MP4 · 1.5 MBEvidence control forms - CEN16MA036Item 59 · PDF · 41 pages · 843 KBExecuflight submissionItem 60 · PDF · 8 pages · 3.6 MB
All 63 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.