# NTSB DEN03FA155: Hawker Siddeley HS-125-700A, N45BP, Beaumont, TX, September 20, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 20, 2003, 18:54 local (23:54 UTC) - Place: Beaumont, TX - Coordinates: 30.111665, -94.25222 - Nearby events: https://openairdocs.org/map.md?lat=30.1117&lon=-94.2522&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report September 29, 2004 - Report: Approved by Office Director - Parties: Starflite Management Group, Inc., Honeywell, FAA Flight Standards District Office, Raytheon Aircraft Company - NTSB case key (mKey): 57966 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN03FA155 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57966/pdf - Page: https://openairdocs.org/ntsb/DEN03FA155 ## Probable cause the first pilot's failure to maintain aircraft control and adequate airspeed. Contributing factors included performing intentional stalls at too low an altitude to afford a safe recovery, the pilot's failure to add power in an attempt to recover, and the flight instructor's inadequate supervision of the flight. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - airspeed - not maintained, dual student (cause) - stall - intentional, dual student - altitude - low, dual student (contributing factor) - aircraft control - not maintained, dual student (cause) - remedial action - not performed, dual student (contributing factor) - supervision - inadequate, pilot in command(cfi) (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - swampy ## Analysis The purpose of the flight was for the instructor-pilot to prepare the first and second pilots for their FAA Part 135 competency and proficiency checks scheduled to be conducted in the accident airplane the following week, with operator proving tests to follow shortly thereafter. The first pilot obtained a computer science corporation (CSC) direct user access terminal service (DUATS) weather briefing and filed an instrument flight rules (IFR) flight plan. The instructor-pilot was listed as the pilot-in-command. The airplane took off and proceeded to its designated practice area. According to the cockpit voice recorder (CVR), the pilots practiced various maneuvers under the direction of the instructor-pilot, including steep turns and approaches to stalls. Then the first pilot was asked the to demonstrate an approach-to-landing stall. The first pilot asked the instructor-pilot if he had "ever done stalls in the airplane?" The instructor-pilot replied, "It's been awhile." The first pilot remarked, "This is the first time I've probably done stalls in a jet. Nah, I take that back, I've done them in a (Lear)." The instructor-pilot said he had stalled "the JetStar on a [FAR] one thirty five ride." Flaps were extended and the landing gear was lowered. Digital electronic engine control (DEEC) recorded a power reduction that remained at idle. According to national track analysis program (NTAP) data, the stall was initiated from an altitude of 5,000 feet. The stick shaker sounded and shortly thereafter, the recording ended. The consensus of 25 witness' observations was that the airplane was flying at low altitude and doing "erratic maneuvers." One witness said it "seemed to stop in midair," then pitched nose down. Some witnesses said that the airplane was spinning. Other witnesses said it was in a flat spin. Still another witness said the airplane fell "like a falling leaf." The airplane impacted marshy terrain in a nose-down, wings-level attitude. Wreckage examination revealed the landing gear was down and the flaps were set to 25 degrees. Both engines' compressor/turbine section blades were gouged and bent in the opposite direction of rotation, and there were rotational scoring marks on both cases. No discrepancies were noted. ## Factual narrative HISTORY OF FLIGHT On September 20, 2003, at 1854 central daylight time, a Hawker Siddeley HS-125-700A, N45BP, operated by Starflite Management Group, Inc., of Houston, Texas, was destroyed when it impacted terrain approximately 15 miles northwest of Southeast Texas Regional Airport (BPT), Beaumont, Texas. The airline transport certificated flight instructor, and the airline transport pilot and commercial pilot who were receiving instruction (hereinafter referred to as the instructor-pilot, first pilot, and second pilot, respectively) were fatally injured. Visual meteorological conditions prevailed. An IFR (instrument flight rules) flight plan had been filed for the instructional flight being conducted under Title 14 CFR (Code of Federal Regulations) Part 91. The flight originated at Houston-Hobby Airport (HOU), Houston, Texas, at 1759. According to the Federal Aviation Administration (FAA), the instructor-pilot was preparing the first and second pilots for their FAA Part 135 competency and proficiency checks scheduled to be conducted in the accident airplane the following week. Operator proving tests were to follow shortly thereafter. The operator, Starflite Aviation, had five other airplanes on its air carrier certificate: a Beech 200 King Air, an IA-1121 Commodore Jet, two IA-1124 Westwinds, and a Lockheed L-1329 JetStar. According to FAA documents, the first pilot obtained a CSC (Computer Science Corporation) DUATS (Direct User Access Terminal Service) weather briefing and filed an IFR flight plan, indicating the airplane would fly to Beaumont in 23 minutes at 250 KTAS (knots true airspeed) and at 5,000 feet. The instructor-pilot was listed as the pilot-in-command. An IFR clearance to Beaumont was issued at 1748, and taxi clearance to runway 22 came at 1749. After the 1759 takeoff, the crew contacted Houston Departure Control at 1801, and was handed off to Beaumont Approach Control at 1810. At 1815, the flight was cleared into a practice area, the boundaries being between the 270-degree and 360 degree radials and within 20 DME (Distance Measuring Equipment) miles of the Beaumont VORTAC (Very high frequency Omnidirectional Radio range TACtical Air Navigation). The airplane was to remain between 5,000 and 7,000 feet msl. At 1828, Beaumont Approach Control instructed the crew to turn eastbound because they was approaching the fringes of its practice area and entering Houston airspace. The crew acknowledged and said that they were turning around. That was the last radio contact with the airplane. The closed-loop cockpit voice recorder, that records ambient cockpit sounds for the past 30 minutes, started at 1822:50 and ended at 1854:27. Only the last 13 minutes of the recording, beginning at 1841:14 and ending at 1854:27, were transcribed. Prior to the start of the transcript, several steep turns and stalls had been performed. The second pilot was complimented on his performance. He remarked that he had never flown a jet before and would have to get use to its feel. The instructor-pilot then asked the first pilot to perform a stall in the approach configuration. The first pilot asked the instructor-pilot if he had "ever done stalls in the airplane?" The instructor-pilot replied, "It's been awhile." The first pilot remarked, "This is the first time I've probably done stalls in a jet. Nah, I take that back, I've done them in a (Lear)." The instructor-pilot said he had stalled "the JetStar on a [FAR] one thirty five ride." At 1848:18, the first pilot asked for approach flaps (15 degrees) and for the landing gear to be lowered. The second pilot complied. The stall was performed and the recovery was accomplished. At 1849:57, the second pilot announced, "Five thousand feet, gear's up and locked. Vee two plus twenty, your flaps [are] up." At 1850:22, the instructor-pilot briefed the pilots on the next maneuver, an approach-to-landing stall: "Okay, accelerate back to two hundred knots, five thousand feet. Find the ref[erence] speed. Do the checklist for the ref speed for our weight. We're at uh fourteen and seven is twenty one. Approach to landing stall is next. What did I say, twenty one? One twenty two for the ref. Your power is gonna be back at idle, you know. What else? Flaps. You know, approach flaps, gear. You don't wanna get flaps in there * late. No, no more trimming past, I think its one fifty or one sixty. Recover. Just like a go-around maneuver. Power, positive rate, flaps ten, okay, positive rate. Gear up. Ref plus twenty. Flaps up." The second pilot questioned the configuration: "So this one the flaps don't go all the way to forty-five, they just go to twenty-five?" The instructor-pilot said, "No, full flaps." A discussion followed as to whether the stall should be performed in a turn or straight ahead. It was decided that the stall would be done straight ahead. At 1852:58, the first pilot asked for approach flaps and then for the landing gear to be lowered. The second pilot then reported, "Flaps twenty-five, set." The first pilot said, "Flaps," and the second pilot replied, "Flaps," and there was the sound of a click. The instructor-pilot reminded them, "*** power," and there followed the sound of decreasing power. According to the digital electronic engine control (DEEC) data, power decreased to 37 percent N1. At 1953:57, the stick shaker sounded. Radar-computed ground speed was 192 knots and decreasing rapidly. Altitude was 4,900 feet msl. DEEC data depicted a commanded increase to takeoff power and the instructor-pilot said, "Aww, don't do that now." DEEC data then showed a commanded power reduction to between 30 and 40 percent N1. At 1854:03, the first pilot said, "Gimme flaps." At 1854:08, the second pilot asked, "What do you want me to do?" Ground speed was between 112 and 113 knots. At 1854:10, the first pilot said, "Recover." There was the sound of increasing background noise, and at 1854:17, the second pilot said, "Power up, power up, power. Do something, man." The instructor-pilot said, "Power up." DEEC data did not record any increase in power, even though both engines were operating and controllable by pilot command. The CVR recording ended at 1854:27. Shortly thereafter, during the 1854 time frame, Beaumont Approach Control gave the flight a new altimeter setting. There was no acknowledgement. At 1855, the approach controller advised that he was not receiving the airplane's transponder signal. There was no reply. Repetitive calls were made at 1855, 1856, and 1908. There was no response to either call. Twenty-five witnesses were either interviewed by telephone or in person. The consensus was that the airplane was flying at a low altitude and doing "erratic maneuvers." One witness said that when airplane emerged from the overcast, it "seemed to stop in midair," then it pitched nose down and disappeared behind the tree line. Several witnesses said the airplane was spinning --- some described it as a flat spin --- before it struck the marshy ground. One witness said the airplane fell "like a falling leaf." The accident occurred during the hours of daylight at a location of 030 degrees, 08.44 minutes north latitude, and 094 degrees, 13.19 minutes west longitude, and at an elevation of 12 feet msl. CREW INFORMATION According to Title 14 CFR Part 1.1, the "pilot in command" is the person who: "(1) has final authority and responsibility for the operation and safety of the flight, (2) has been designated as pilot in command before or during the flight, and (3) holds the appropriate category, class, and type rating, if appropriate, for the conduct of the flight." Based on this definition, the pilot-in-command was the instructor-pilot, who, according to the CVR transcript, was seated in the jump seat. The instructor-pilot was also listed on the filed flight plan as being the pilot-in-command. The instructor-pilot, age 36, held an airline transport pilot certificate, dated November 19, 2002, with an airpla ## Aircraft - Registration: [N45BP](https://openairdocs.org/deregistered/N45BP-2005-07-15), registration cancelled 2005-07-15, S/N NA0219, built 1978 (OpenAirDocs) - Reported make and model: Hawker Siddeley HS-125-700A - Registry model: [Hawker Siddeley HS.125 SERIES 700A](https://openairdocs.org/model/hawker-siddeley-hs-125-series-700a) (registry code 4230170) (OpenAirDocs) - Registry engine: [Garrett TFE731 series](https://openairdocs.org/engine/garrett-tfe731-series) (registry code 29001, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: NA0219 - Airframe hours: 9781 - Engines: Garrett TFE-731-3-1RH 3700 lbs thrust turbo fan - Damage: Destroyed - Flight: Instructional, Part 91 - Registered owner: Starflite Management Group, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, August 1, 2003, 43 hours before - Departed: HOU, Houston, TX - Destination: BPT, Beaumont, TX - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 36; injuries: fatal; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: center; toxicology performed; flight hours: 5,230 total, 3,521 as pilot in command - Pilot; age 42; injuries: fatal; commercial, airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: helicopter; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 3,817 total, 2,684 as pilot in command - Pilot; age 27; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 2,400 total, 2,200 as pilot in command - Pilot; age 42; injuries: fatal; flight instructor, commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed - Pilot; age 27; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: rear ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 7 knots - Visibility: 8 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 70 °F - Altimeter: 29.97 inHg - Observed at: KBPT ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20030920026169A](https://openairdocs.org/incident/20030920026169A), Sep 20, 2003: Braero HS125700A, Beaumont, TX, Destroyed, 3 fatal. (-23) Aircraft destroyed and fatal injuries to all three pilots aboard. Several eyewitnesses described a flat spin of only several turns with rotation which… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.