NTSB Blames Pilot in Maryland Phenom Accident

The pilot of an Embraer Phenom 100 failed to turn on either the jet’s engine anti-ice or structural de-ice system during the last 15 minutes of a December 8, 2014, instrument approach despite flying in known icing conditions. The pilot also selected an approach airspeed that was too slow for flight in ice, according to findings released Tuesday by the National Transportation Safety Board. The Board was unable to determine exactly why the pilot failed to turn on the icing systems during the final moments of the flight.

The Phenom stalled at 300 feet AGL, then crashed less than a mile short of Runway 14 at Montgomery County Airpark in Gaithersburg, Maryland (GAI), killing the pilot and two passengers. Three people on the ground also died when the aircraft struck three homes, igniting a fire. GAI weather was reported as marginal VFR with a temperature of 28 degrees Fahrenheit. The aircraft was operating under Part 91 on an IFR flight plan.

The NTSB said a contributing factor to the accident was the pilot’s apparent rush to reach GAI, a view supported by interviews with line personnel at the departure airport in Chapel Hill, North Carolina. The NTSB learned that a normal startup checklist took an experienced Phenom pilot about nine minutes to complete. Data from the digital data recorder on the Phenom indicated the pilot skipped some checklist items entirely when he called ready for departure just six minutes after climbing aboard the aircraft. During the rush, the pilot failed to enter accurate weights into the Garmin avionics system prior to takeoff, which created the inaccurate landing speeds at GAI. In icing conditions, the Board determined the Phenom’s approach speed should have been 126, with final flaps set to 3. The Phenom stalled on final at 92 knots, with flaps set to 4.

The Board praised Embraer for its standard installation of digital cockpit and flight data recorders on Phenoms. Without them, the Board would never have known, for example, that some of the checklist items had been skipped. The NTSB developed three recommendations during the investigation, including one to the FAA to “Work with the General Aviation Manufacturers Association to develop a system that can automatically alert pilots when the ice protection systems should be activated on turbofan airplanes that require a type rating and are certified for single-pilot operations and flight in icing conditions.”