Aftermath: Unstabilized Approach

Accident analysis that goes behind and beyond the NTSB report. Flying

The Hawker jet was descending through 13,500 feet, near the end of a 34-minute hop from Dayton, Ohio, to Akron Fulton Airport, when one of the passengers leaned through the cockpit door.

“You guys know where we’re going, right?”

It was a joke, but it wasn’t far off the mark.

The National Transportation Safety Board’s account of the Hawker’s November 2015 crash, which took the lives of the jet’s two pilots and of seven employees of the Florida real estate firm that chartered it, is chilling to read. It is a tale of a first officer — the pilot flying, despite an informal company policy that gave all revenue legs to the captain — who seemingly lacked both knowledge and skill, and a captain who failed to take control of the airplane even though he clearly saw that the first officer was out of his depth.

The cockpit voice recorder (CVR) was defective, and the recording of cockpit conversation throughout the short flight was sometimes difficult to understand. The transcript has an odd quality of uncertainty and incoherence, with sentence fragments flying about, topics broached and quickly abandoned, apparent confusion about elementary aeronautical knowledge, an approach briefing gone astray, and the captain’s growing impatience with the first officer’s confusion and lack of focus.

They were not strangers to each other. They had flown some 32 hours together on three prior occasions. The first officer, 50, had 4,400 hours. He had a multiengine ATP certificate with an HS-125 type rating and limited type ratings for B737 and Learjet. Early in 2015, he had been terminated by a previous employer because of substandard performance in a B737 second-in-­command training course. He had particular difficulty with ­memory items, which are a large component of qualification in any jet, and persistently “struggled” with weight and balance problems as well. Remedial training — his instructors, the previous employer reported, had gone “well beyond what was expected of them” in trying to bring him up to speed — and hours spent as a jumpseat observer had not helped. The chief pilot of the firm that let him go called his performance “ridiculously weak.”

The first officer had secured his present job through a personal recommendation. Although commercial air carriers are required to investigate the history of their hires, and a report of his woeful performance at his previous job had been provided as required, it had been overlooked or ignored by his new employer. Pilots who had flown with him at his current job were interviewed by an NTSB investigator. None found fault with his flying — not that they had any motive to do so.

Here are excerpts from the CVR transcript, beginning as the jet approaches the localizer:

FO: Where are we? This is the distance from Akron? CAPT: You got your localizer? FO: 280 heading. CAPT: Go 280, but you’re never gonna capture. FO: Let’s see if she’s gonna do it, though. I will try to drag everything. Let’s see what she does. OK, just keep me updated on the distance. CAPT: We are like 7 miles from Akron. OK, we got 9 degrees pitch-up! [Sound of landing gear lowering] CAPT: Did you hear what he say [sic]? There’s an airplane on the approach, slower than us. He hasn’t canceled. We don’t know if he’s on the ground. You can’t! FO: Why? CAPT: You need to look. I mean, we were flying like 139, 9 ­degrees pitch-up. Look, you’re going 120. You can’t keep decreasing your speed. FO: How do you get 120? CAPT: 125. Vref plus 15. FO: Which is the approach speed. CAPT: You’ve still got flaps to go. FO: And when you put them — CAPT: That’s what I’m saying. If you keep decreasing your speed— FO: But why? CAPT: Because we’re gonna stall. I don’t want to stall. FO: Four miles. Full flaps. CAPT: Gear down. Before landing. Three lights, one and — FO: All right, we go to minimums. CAPT: All right. FO: Can you check if I got everything? Ignition — CAPT: Everything is all set. Stand by. Yaw damper. Autopilot. Main air valves. I’ll take care of them. FO: All right. CAPT: Vref. On localizer. You’re diving. Don’t dive. Two thousand feet per minute, buddy! FO: Yeah. CAPT: Two thousand feet per minute — don’t go 2,000 feet per minute! … Don’t go 2,000 feet per minute when you’re 1,500 feet above the ground or minimums. Ground. Keep going. One point one is for the missed approach. OK, level off, guy! [Sound of rattle, similar to stick shaker] FO: Got it. [Sound of rattle] CAPT: Oh [expletive]! Focus! GPWS: Pull up! CAPT and FO: Oh, oh, oh, oh!

The Hawker’s left wing stalled first. The airplane rolled left, nose high; the power came up with a roar. One witness said, “It’s like the ground just sucked the plane in.” It careened into an unoccupied apartment building and exploded into flames.

NTSB investigators assumed that the FO set flaps at 25 degrees while still outside the FAF. The indicated airspeed was 125 knots — it should have been 144 — and the Hawker was established on the localizer. The descent to the FAF, crossing an altitude of 2,300 feet, should have begun when the airplane captured the localizer, but instead the FO lingered at 3,000. The captain failed to ­notice the discrepancy, which proved a fateful mistake.

The conversation about speed suggests that the FO thought it was OK to slow to the full-flap Vref, 124 knots, even though he had only 25 degrees of flap, because he would soon be going to full flaps anyway. This did not make much sense; the correct Vref for flaps at 25 degrees was 20 knots above the full-flap speed, and they could hardly be treated as equivalent. At this point, the NTSB thought, the captain should have taken control.

The FO remained at 3,000 feet until 4 miles from the threshold. At that point, he apparently realized for the first time that he had very little room in which to descend to the MDA (1,540 feet msl). He called for full flaps and allowed his rate of descent to increase to 2,000 fpm.

Normally, a nonprecision approach in the Hawker — an airplane with good low-speed handling that becomes a dog with gear down and full flaps — would be flown with flaps at 25 degrees and a rate of descent of 1,000 fpm down to the MDA. Full flaps should be used only for the final descent, when the landing is assured.

At the MDA, it was necessary to arrest the rapid ­descent. Unfortunately, however, at this point the first officer had allowed the speed to bleed down to 110 knots, only 12 knots above the stall. He had painted the jet into a corner. There was no excess energy to work with and very little angle of attack, and the drag of the flaps kept the airplane from accelerating.

Many unstabilized approaches can be safely salvaged; the ones we find out about are the ones that go wrong. The captain evidently believed that the FO would be able to salvage this one — otherwise, why did he not ­intervene? But pilots have good days and bad ones, like everybody else. Standard operating procedures are ­supposed to protect you against your worst days, but they work only if you adhere to them.

Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, "Technicalities" and "Aftermath," with FLYING readers.

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