Operational Failures: Execuflight 1526 Part Two

16 Feb 18 12 Comments

On the 10th of November 2015, a BAe 125 operated by Execuflight crashed into an apartment building while on approach to Akron Fulton International Airport. The captain, the first officer and seven passengers died.

I looked at the flight in Trouble in the Cockpit: Execuflight 1526 Part One. The key question, which we discussed in the comments, was how the situation in cockpit degenerated so badly that a routine approach turned into a fatal accident. Clearly the CRM (Cockpit Resource Management) had fallen to pieces. Fatigue was mentioned, as well as lack of leadership skills and flat out incompetence.

Accident site

One unexpected issue that came up during the investigation was the weight and balance. The British Aerospace HS 125-700A serial number 257072 had a basic weight of 13,815 pounds (6,266 kg). The operatating weight was documented as 17,276.92 pounds.

Then in 2014, the APU auxiliary power unit was removed, reducing the basic operating weight by 300 pounds (136 kg). This is noted on the weight and balance record, with the basic operating weight amended to 13,976 pounds. Except that there’s no mention in the aircraft maintenance records of this ever happening. There is a mantenance record from 2015 which refers to an unserviceable APU which was removed and then replaced with a serviceable APU. Certainly, an APU was found in the wreckage. But somehow, that 300 pounds was never added back to the weight and balance.

Not that it mattered. Because, when they checked the weight and balance computation for the flight and also the previous flights on the two-day trip, it was clear that the computations used the aircraft’s basic empty weight of 13,815 pounds instead of the actual operating weight of 14,276 pounds. So they’d already lost over 300 pounds to their starting weight when doing the calculations.

They used a program called Ultra-Nav which had the basic empty weight as the default setting, instead of the basic operating weight. The chief pilot said he didn’t know what the default setting was in the program, as any crew member who had access to the system could change the default. There’s no way of knowing who entered the basic empty weight instead of the basic operating weight.

The other mistake seems almost trivial in the scheme of things but I think is worth mentioning. The captain hadn’t filed an alternate airport for the flight plan of the accident flight. More importantly, this was not a one off.

From the official accident report

A review of the available past flight plans filed by the captain while operating as PIC for Execuflight between August 28, 2015, and November 10, 2015, revealed four other flights for which an alternate airport was required but not filed, including the flight before the accident flight from LUK to MGY. This indicated a recent history on the part of the captain of failing to file an alternate airport on a flight plan as required by federal regulations. In addition, the captain’s history of failing to file an alternate airport when one was required indicates that Execuflight management had a history of failing to verify that an appropriate flight plan was filed before departure of each flight as required by company procedures.

The investigation found that the pilots sent the Ultra-Nav printouts to the chief pilot and not the completed flight logs.

Flight logs for 9th and 10th November were found at the accident site and it turned out that the weight and balance on these didn’t match the numbers on the Ultra-Nav print outs sent to the chief pilot. There were no entries on the flight log for the accident flight at all. The NTSB reconstructed the weight and balance as best they could, although they didn’t have the weights of the passengers and the baggage, subtracting fuel burn and came to an estimated landing weight of 22,286 pounds. The BAe 125’s maximum landing weight was 22,000 pounds.

At their actual weight, as opposed to the logged weight, VREF (landing reference speed, or, the speed at which you should cross the threshold in a landing configuration at a height of about 50 feet) was 125 knots at flaps 45°.

With that information, we can revisit their descent. At the FAF crossing altitude they were going 120 knots. At the point when they were descending at 2,000 feet per minutes, the airspeed was down to 118 knots. At the MDA they were flying 113 knots and, as they descended past it, the stick shaker activated. The first officer levelled off but did not add thrust, and the recording ended.

Now, it’s not exactly surprising that they stalled and the weight and balance can’t be said to have caused the crash. But I think it gives some interesting insights into the operations.

While we’re looking at the flight logs, let’s take a look at the previous flights of the crew. The captain’s details are straight forward: he was off duty on the 6th and 7th of November. He flew a day trip on the 8th of November, on duty from 07:50 to 13:05. Then he was off work until the two-day charter of seven legs. So he was nicely rested and ready to go.

The first officer’s week was a little bit more hectic.

On the 6th and 7th of November, the first officer was paired with a different captain for a two-day trip from Fort Lauderdale, FL to Teterboro, NJ and back.

On the 6th, he was on duty from 0800 to 1300, when they arrived at Teterboro. The following day, he and the captain checked out of their hotel at 12:10 and took a shuttle from the hotel to the airport. They arrived some time after 14:00 and the first officer began work, conducting all the pre-flight preparation for the next leg of the trip. The flight log shows that they came on duty at 15:00. The captain sent a text message to the dispatcher at 16:53 stating doors closed for the flight back to Fort Lauderdale.

The allowable length of a flight duty period depends on when the pilot’s day begins and the number of flight segments he or she is expected to fly, and ranges from 9-14 hours for single crew operations. The flight duty period begins when a flightcrew member is required to report for duty with the intention of conducting a flight and ends when the aircraft is parked after the last flight. It includes the period of time before a flight or between flights that a pilot is working without an intervening rest period. Flight duty includes deadhead transportation, training in an aircraft or flight simulator, and airport standby or reserve duty if these tasks occur before a flight or between flights without an intervening required rest period.

Execuflight’s president was the operations management person on duty. He said that the first officer did not come on duty at 15:00 on the 7th but instead came on duty at 17:15, which would mean that the first officer had ten hours of consecutive rest in the preceding twenty four hours. He said he’d specifically instructed the first officer not to go to the airport until shortly before the flight. When asked if anyone had checked up on this, he said that the chief pilot and the first officer discussed the duty time and whether it would be OK or not OK for the first officer to make the trip.

Execuflight’s president gave sworn testimony that the officer came on duty after the captain, starting at 17:15, and thus had his ten hours rest. But the hotel records, the doors closed message and the sworn testimony of the captain of that flight tell a different story.

Execuflight then asked the two pilots to fly an overnight trip to Mexico. The captain of the two-day flight said that they couldn’t, as it would cause both of them to exceed their duty time.

The flight arrived back at Fort Lauderdale at 20:06. When they landed, the chief pilot met them and told the first officer that he was needed for the overnight trip to Mexico, departing at 20:40. The captain of the flight was the chief pilot.

The first officer finished his duty period at 07:15 on the 8th. The two-day trip captain spoke to the first officer that evening. The first officer said that he was tired from the overnight trip and that he’d expected to stay overnight in Mexico, but they ended up flying all night and coming back.

Execuflight’s president said that they always had the option to stay in Mexico if they were breaking duty time.

At this stage, he’d had 7 hours and 45 minutes consecutive rest in the preceeding 24 hours.

From 09:17 to 17:04 he had a rest period and the opportunity to sleep. He sent a text message at 12:53. Other than that, we don’t know anything about his rest pattern but it doesn’t look good.

The FAA overhauled the pilot fatigue rules in 2011. As of the current rules for passenger airline pilots, the flight time limits are eight or nine hours (depending on start time) with a ten-hour minimum rest period prior to the flight duty period, with an opportunity for eight hours of unterrupted sleep within the ten hours. They must also have at least 30 consecutive hours free from duty on a weekly basis.

On the evening of the 8th of November, the first officer finally had a rest period of over ten hours, with a sleep opportunity from 19:15 that evening to 05:50 the next morning, when he rose to meet the captain of the accident flight for their seven-leg charter flight. That day, the two pilots were on duty from 05:50 to 20:30, a total of 14 hours and 40 minutes.

The following day, they got up at 09:00 and departed Cincinnati for the half hour flight to Dayton. The captain filed the IFR flight plan for Akron, Ohio, departing at 13:30. They actually departed at 14:13. Not a tough day in itself but it isn’t hard to see from this schedule that the first officer must have been tired and really, really ready for a day off.

Now his fixation and inability to take in what the captain was saying makes a lot more sense. At that stage, he just couldn’t keep track of anything any more.

The thing is (and I want to say this gently, because the poor man lost his life over this) he wasn’t an excellent pilot in the first place. When he started at Execuflight, he was fifty and had worked as a first officer for eight years.

From 2007 to 2011, he was employed by Personal Jet as a first officer on the Hawker and Learjet. From 2012-2014 he worked as a first officer for Chauff Air and in 2014 he was hired as a first officer on a Boeing 737 for Sky King.

Sky King reported that he started to fall behind and that he “struggled” with memory items and weight and balance problems. The Sky King check airman described the first officer’s performance in the simulator as “ridiculously weak”.

After a few months, they struggled with his “lack of acceptable progression” and had him fly as a jump seat observer for a week to pick up some 16 hours of observation experience. At the end of that, they ranked his progression as “significantly below acceptable standards.” He was let go, with “unsatisfactory work performance” given as the reason.

Three months later, he was hired by Execuflight.

Now, there’s specific legislation in the US to ensure that operators adequately invesitgate a pilot’s background before allowing him or her to conduct commercial air carrier flights. Before you can put the pilot in the cockpit, you have to review the last five years of the pilot’s background and other safety-related records. The Pilot Records Improvement Act (PRIA) requires all previous air carriers to provide employee records pertaining to the individual’s performance as a pilot, with a specific focus on training, qualifications, proficiency and professional competence.

The Execuflight General Operations Manual stated that the president was responsible for recruiting and terminating all company personnel. The duties of the director of operations included conducting personnel interviews and recommending personnel actions to the president.

The director of operations (who has since left the company) said he was not involved in hiring of either of the pilots. The president agreed that he’d hired both pilots but said that he’d delegated the review of PRIA records to the chief pilot. The chief pilot said that the hiring was done by the president. He had no idea that the first officer had been fired by Sky King.

Execuflight’s president stated that he hired the first officer based on a recommendation from another pilot and a Part 91 flight that he made with the first officer. When asked about the first officer’s PRIA background check, the president stated that he was “not too familiar” with the PRIA records because the chief pilot was the one who “does all the due diligence in that respect.” He further stated that he did not “really home in on” the first officer as he was hiring him as an SIC and “didn’t get in deep into his file.”

The Sky King check airman confirmed that no one from Execuflight ever contacted him to follow up or to ask for additional information.

No remedial training was offered to the first officer. He was simply put to work. With his history of struggling with memory items and weight and balance, in an aircraft above its maximum weight, fatigued after a week of heavy flying, it’s hardly surprising he couldn’t make sense of the Akron approach.

Main Wreckage

However, this still doesn’t explain why the captain let him have control on a revenue flight and why the captain didn’t take over when he realized that the first officer wasn’t coping. He was 40 and had no prior accidents or incidents, just a single enforcement action for operating an aircraft contrary to an ATC instruction.

Execuflight supplied PRIA documentation which referred to itemized records from his previous employer but did not actually include any copies of those records.

Execuflight’s president stated that he’d hired the captain based on his background, including his previous experience in the Hawker. He said that the background check showed an “administrative issue” related to a communication course and that the captain left his previous post voluntarily. He did not contact the previous employer to ask for additional background information.

However, he had too been fired from his previous employment. He was scheduled for recurrent training on the Hawker 800A and didn’t attend the training, for which he was terminated.

The FAA requires every operator to offer an approved CRM (Cockpit Resource Management) training, which at Execuflight was offered through lectures and a PowerPoint presentation by the chief pilot. The content was copy and pasted from the appendix of the Code of Federal Regulations (CFR) which is meant to assist organizations in program and curriculum development. In other words, it’s a list of issues that should be taught and not meant as the actual training content. At the end of the training, each pilot took a ten question test and was required to have a ‘non-corrected passing grade of 80%’. If a pilot scored under 80%, then the pilot was to review the ten questions and receive a corrected grade to 100%. The test questions and answers were provided in the CRM manual, making revision easy.

The captain’s answer sheet had 100% written in the box for the uncorrected grade. The box for the corrected grade was blank. Looking at the answers, however, the captain only got four questions correct: his uncorrected grade should have been 40%.

Specific areas of weakness: responsibilities of the Pilot in Command, flight deck management and aeronautical decision-making.

(For what it’s worth, the first officer got 70% uncorrected and 80% corrected.)

Although both pilots had attended sim training at Execuflight, the captain was paired with a pilot from a different operator and the first officer was paired with an instructor. As a result, neither pilot had the opportunity to practise CRM. There was no scenario-based training or line-oriented flight training, thus no reinforcement of CRM principles as a part of the simulator training.

The FAA principal operations inspector responsible for the oversight of Execuflight clearly dropped the ball. He had certified the operator in 2004 and, in the intervening time, he oversaw 16 certificates of which 14 were Part 135 operators like Execuflight. His workload was “very busy” and, although he’d visited the operator a few times a year and conducted line and ramp checks, he didn’t know what pilots did in normal operations. He only saw them during line checks, which weren’t performed on revenue flights. When the captain received his line check when he started his employment in June 2015, the inspector did not directly administer it, instead, he observed Execujet’s chief pilot who conducted the captain’s line check.

The POI considered Execuflight to be a “very good operator,” and, in general, he felt Execuflight did a “pretty good job.” According to the POI, he was aware that the position of director of operations was vacant at the time of the accident and that Execuflight was in the process of trying to fill it. The POI stated that the chief pilot temporarily took over some of the duties and did an “excellent” job.

The report concluded that the captain should have taken control or called for a missed approach before the aircraft ever reached the Final Approach Fix (FAF) when the first officer reduced the airspeed, putting the aircraft in danger of a stall. After they descended past the MDA, the captain said ‘okay, level off guy’ instead of calling for a missed approach. The stick shaker went off. The last radar data of the aircraft shows that the aircraft was about 1,300 feet above mean sea level, with an estimated speed of 98 knots and an estimated angle of attack of 20°. The critical angle of attack for the aircraft, that is, the point at which any further increase will decrease lift and cause the aircraft to stall, was 15.5°.

Although the captain clearly recognized that the first officer was having difficulty flying the approach, he did not intervene either before the airplane reached the FAF when he noted the first officer was not maintaining the proper airspeed or after the airplane passed the FAF when he noted that the first officer was exceeding the proper vertical speed. Rather, the captain inappropriately adopted the duties of a flight instructor and did so ineffectively as demonstrated by his failure to ensure the safety of flight as he coached the first officer through the approach. The NTSB concludes that the captain’s failure to enforce adherence to SOPs and his mismanagement of the approach placed the airplane in an unsafe situation that ultimately resulted in the loss of control.

Before we finish, I just want to refer back to the Execuflight’s comment to the press at the time of the accident.

Planes just generally don’t fall out of the sky. I can tell you that they were very well seasoned pilots, both of them. They like to fly together. We monitor the flights leg by leg since it started and it’s typical for them to give us a doors open, doors closed message, we’ve got them all.

The two pilots had flown together three times in the 90 days before the accident. But more importantly, this throw-away statement to the press reinforces another finding by the NTSB: the staff at Execuflight kept track of the aircraft through the doors open and doors closed text messages, but they did not appear to consistently review other aspects of the flight: the fuel, the weight and balance, the flight plan.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was 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.

In addition to the recommendation, there was a Board Member Statement which I found uncommonly powerful.

I believe the organization that chartered this aircraft expected to get a professionally managed aircraft. I suspect they expected to get a professionally flown aircraft. And, I further believe they expected that when the regulator, the Federal Aviation Administration, issued an Air Carrier Certificate to Execuflight, they expected the FAA to provide adequate surveillance of Execuflight. Tragically, as this investigation found, those charter customers did not get what they expected or deserved in any of these respects. Their expectations were based on a house of cards that created an illusion of safety.

The statement focuses on this illusion of safety and calls out both the lack of regulatory oversight and failure of industry audits, as the operator held an ARGUS Gold rating and was Wyvern Registered, both seals of approval which offer customers the security that they are choosing a respected and safe air travel provider.

I’m glad to see the statement. It’s depressing to see an American accident in 2015 with all the hallmarks of a cowboy operation of what I had hoped was a time gone by. There’s no excuse any more for disregarding the importance of good CRM and of protecting pilots from fatigue. I’m also glad to see that the FAA was called out for not seeing the operator’s issues, for failing to spot the standard disregard for SOPs that appears to have been endemic within the company.

Paying passengers should be able to feel secure that flying is safe, whether in a Boeing 747 or a ten-seater business jet. I spend a lot of time trying to convince the general public that they are not taking their lives into their hands every time they consider a flight. Situations like this really does aviation’s reputation no good at all.

The full NTSB report, including the board member’s statement, can be found online on the NTSB site: Crash During Nonprecision Instrument Approach to Landing Execuflight Flight 1526

Category: Accident Reports,

12 Comments

  • Sylvia,
    Your concluding statement is “right on the money”. It is perhaps a bit unfortunate that aviation, especially FAR Part 135 operations, can get away with far too much, simply because the FAA simply does not have adequate resources to properly supervise them all.
    In a country like Ireland and also in the Netherlands, at least when I was working there, the aviation community is very much smaller. Pilots and inspectors know one another, not seldom on a first-name basis. That may seem like a cosy arrangement but if was anything but. It could take years to build up a good reputation with the respective CAA and it could take less than minutes to lose it. And knowing an inspector did not guarantee any leeway when it came to missing a check ride.
    An operation like Execuflight would have lost its AOC long before that fateful incident.
    I do not want to put blame on individual inspectors. The system just has grown out of proportion to the authorities’ ability to monitor, supervise and audit them all. And some “cowboy operators” use the presumed supervision as a smoke screen.
    Where I blame the pilots, especially the captain, is that he obviously had lost sight of the need to adhere to any standard at all and violated his duties that would have required him to see to it that his flight would be conducted at an acceptable professional level.
    “Kick the tyres, light the fires” seemed to have been the driving force.

    • While I’m not a pilot, I do work professionally in safety. I agree with Rudy and Sylvia that the crew did not come across as focused on their duties and responsibilities in the way that they should have, and as the Board Member states, their customers expected them to.
      I found the company’s focus on the ‘doors closed’ and similar messages interesting – I would not be surprised to find that those messages and times are tied to either company revenue or employee pay; in other words, if that is the case, the company was focused on costs more than on safe operation. Their inadequate training would also support this argument – their simple presentation in house by an employee would have been MUCH cheaper than bringing in a consultant with approved training, and their oddly split simulator time suggests to me that the company was trying to keep their simulator costs down as well.
      I wonder how competitive the executive transport market is? How many other companies scrimp like this and just haven’t been tripped up by it yet?

  • Jonathan,
    To me, as a (former) airline- and corporate jet captain a message from the crew to the company like “doors closed” is in itself not significant. It merely informs the company that the flight is about to depart. Which of course can affect other aspects of an operation like impact on the next flight, crew duty times, etc. Airlines of course have ground handling staff to liaise with the flight operations department. In the USA small air taxi operators (FAR 135) often use small airports with fixed base operators that allow use of their lounge at a nominal charge. Landing fees are also usually much lower than in Europe. Their money is made by providing fuel, catering and all kinds of other services.
    In Europe, the FBOs (Handling agents) usually charge hefty fees that are not optional. On top of that landing fees can be substantial. A very different structure. It allows for a lot more competition in the USA. Costs are in general lower but in some cases, because of the greater number of competing operators, so can be standards.
    Simulator training is usually bought by the operator in time blocks. The company will decide what pilots are due to be rostered for “recurrent training”. It is common practice to put two pilots together as if they were to go on a normal line flight.
    From what I read, Execuflight’s crew hiring, training, supervision and in general tracking of their records and performance was a shambolic affair. The people who should have been, and were responsible did not consult with one another, did not pass on essential information; all they were passing was “the buck”.
    A captain who scores 40% on a knowledge test has no business to be in the cockpit, not even as a trainee let alone as pilot in command.
    The whole saga reads to me as an indictment for CRIMINAL neglect from the side of management.
    How inspectors could deem this operation to be at a satisfactory standard seems to me one of those cases where a lack of resources led the inspectors to be hoodwinked into accepting the word from the management. Where I come from, inspections also cover crew training records, weight and balance and other records, etc.
    How did this company get away with filing flight plans without nominating an alternate?
    Execuflight was operating their flights on a Russian Roulette basis. Considering their absolute lack of any level of operational standards, it was inevitable that one day the trigger would be pulled when the bullet was in the chamber.
    I used the word “criminal” in conjunction with management’s neglect to oversee and maintain acceptable standards and re-reading my comments see no reason to soften it.

    • I’m not saying that I have a problem with the “doors closed” messages and similar administrative matters; my problem is that from what Sylvia presented of the investigation, the management seemed to either ONLY care about them, or to place a higher priority on them than on safety training and documentation.

      • To be fair, the emphasis on this may be my fault. In taking a long report and condensing it, I may be giving the ‘doors closed’ more importance than the NTSB did. Having said that, yes, my understanding of the report is that the NTSB felt that the management of the company were using ‘doors closed’ as their primary information without bothering to check other details and documentation.

  • A final comment should be in order to clarify my scathing comments:
    Not everyone who would like to be a pilot is suitable to become one, which is true for virtually every profession.
    An aviation company that hires people who already have failed to make the grade in other companies but still employs them as pilots, not bothering to do a background check nor giving them any meaningful training in order to rectify deficiencies in their performance, not passing essential information about (far) below acceptable standards and performance: in my considered opinion the management of such a company is coming dangerously close to what could be considered culpable homicide.
    Of course, this is only my own opinion. I am not a lawyer.
    But consider the following:
    The people who were running the company were preying on the natural desire of people who had but a nominal qualification as pilots but still were under the illusion that they would be able to make a career as commercial aviators. They were obviously lacking the skills levels that could, and should be expected from a professional crew. It is understandable that those pilots, being hired by a FAR part 135 operator, were only too willing to believe that they were up to the task, even though the sequence of events in this tragic accident amply demonstrated that they were not.
    The management, training captain, chief pilot, operations manager, in fact anyone in authority in the company and who would have been in charge of or involved in maintenance of the operational standards should have picked up on their lack of skills, should have contacted previous employers, checked training records and should have acted on the findings. Which, at a very minimum, should have resulted in intensive additional training. The company seems to have preferred not to go that route because it would have incurred substantial costs.
    But the cavalier attitude towards standards is also amply demonstrated by the confusion about and lacking of paperwork regarding the removal of an APU which after all was apparently still in the aircraft, resulting in a weight and balance calculation that was not corresponding with reality..
    The fact that the accident was caused because the aircraft stalled is not really attributable to the erroneous weight and balance. The first officer was lacking even basic flying skills and the captain did nothing to correct the situation.
    Which leads to another can of worms: Who was responsible for maintenance and upkeep of the aircraft technical records? The filing of IFR flight plans that routinely lacked a designated alternate is another indicator of very seriously lacking standards.
    This is one of the worst cases of mismanagement in an aviation company that I have ever heard of.

  • The basic issues sound depressingly like the Hanscom fatalities Sylvia reported on two years ago (https://fearoflanding.com/accidents/accident-reports/how-to-drop-a-gulfstream-iv-into-a-ravine-habitual-noncompliance/): a long history of careless-to-non-compliant procedures that finally crashed a plane and killed everyone in it. The main difference is that this was a somewhat larger operation (the carrier in the Hanscom cased owned a single airplane), which meant there were more people who could have said something that would have broken the chain of events — but who may have thought it was more than their job was worth to do so. In terms of their share of the passenger market Execuflight was still a very small operator; In the US we are told over and over that small businesses are the lifeblood of the economy and must not be “overregulated” — but I remember from the few years I worked as a chemistry researcher how much more careful my very large first employer (Dow) was about laboratory safety (even in small pure-research lab a long way from headquarters) than my much smaller last employer (where everyone worked in the same building), and wonder whether there’s a size below which airplane operators can’t make money in a market so oriented toward competition AND spend enough time focusing on maintaining safe procedures rather than generating income.

    Rudy — wrt getting away without filing an alternate, I wonder whether it’s similar to the difficult position of the controller in https://fearoflanding.com/accidents/accident-reports/hes-a-terror-in-a-twin/; when is a government employee permitted to tell a private operator that the operator can’t do what he wants? (Refusing a flight plan from a distance is a lot safer for the refuser than driving out on the runway to block a takeoff, but whoever processed the flight plan would be in a similar fix: what’s the penalty for holding up traffic?) The one time I flew PIC under instrument conditions I was very careful about filing an alternate (and refusing the seriously unsafe routing (for the plane I reported flying) that ATC first gave me) — but I was new enough to be careful (not to mention having my kid sister as my only passenger); I did have to file an (implausible) alternate in that case, but given the poor routing I wonder what I might have gotten away with if I’d been talking to someone else. Also, AFAIK there is no record of flight plans which the PIC was required to modify because the person accepting the plan found an issue, so we don’t know how often this captain had erred but been corrected; it also seems that the FAA doesn’t track any infractions as road authorities frequently track motorist infractions, such that a marginal captain with previous issues would get suspended for something that might call for a lesser penalty when a pilot has a clean record.

  • I hope the families of the deceased sue Execuflight, and I hope the FAA principal operations inspector responsible for the oversight of Execuflight is sanctioned, and either receives more training or finds a job he or she can do.

  • Chip,
    I subscribe to most of your comment, but insofar as I understand, Execuflight was operating on a FAR part 135 licence.
    That means, literally: “Air Taxi Operators and Commercial Operators of small Aircraft,” I retired from flying a long time ago and I do not possess a recent copy but the principle has not changed. The government has a duty towards the general public to oversee such an operation in the interest of safety. In this case, where it concerns public transport, your argument about a government employee “telling a private operator that they cannot do what they want” does not wash.
    Just like if the driver of a car decides that certain aspects of the rules of the road do not apply to him / her because it infringes on their rights as a private citizen. Tell that to the traffic cops.
    I have worked in aviation for a very long time, long enough to have witnessed first-hand a transformation. When I gained my PPL there still were DC3s in airline service. Aviation was a very different world then. But at least pilots were taught to fly aircraft, properly. It was no guarantee for safety and accidents did happen. Over time, aviation authorities worldwide did the right thing: they introduced ever stricter rules and regulations. In tandem with what if seen in the light of the past 50 odd years has been a true revolution in technology. These improvements have totally changed the technology that drives aviation to-day. That, in turn, made it more necessary than ever for civil aviation authorities to clamp down on the “cowboys”. Yes, it reduces their individual freedom but it also has led to aviation becoming the safest form of transport. But unfortunately, the exponential growth of aviation also led to some of the worst operators to avoid scrutiny.
    Operators like Execuflight by ignoring the basic rules that have allowed aviation to become so safe should be stamped out. If that means long jail sentences for the managers, so be it.
    And in response to Mike: Someone in an overseeing capacity in the FAA has blundered, which led indirectly to the deaths of the crew and passengers of this flight. Suspension would seem to be a more appropriate action until an independent investigation is conducted.

  • I re-read the Hanscom incident. the situation there was totally different:
    The operator had good write-ups, a very up-to-date aircraft and pilots who were long-term employees and very familiar, one could say too familiar with the aircraft. So familiar in fact that theyfelt there was no need to perform the proper checklists and even when the cause of the unresponsive controls became evident, and still with sufficient runway ahead to stop, they preferred to try and solve the problem whilst thundering down the runway – to their doom.
    A good operation that became, to use the phrase, “inbred and complacent”.
    The Execuflight incident on the other hand was caused by management that did little or nothing to properly supervise their operation. Modifications to the aircraft were not entered in the technical records, flight plans were filed omitting essentials like alternate airports and they did not even bother to establish whether or not their pilots were at a professional standard.

  • Rudy — I certainly wasn’t saying that Execuflight should get a pass on the rules; the issue is who can enforce those rules and how thoroughly. E.g., I don’t know whether ATC is authorized (and taught that they are authorized) to reject a flight plan filed without an alternate. (It does seem like the management failures should have been discovered — but again, the “duty” of the government is a diffuse concept; without specific laws covering (e.g.) inspection of records, Execuflight could have told FAA representatives to piss off. This is a grey area, but in general in the US the rule is that the private citizen or organization holds most of the cards when the government — especially the federal government — wants to intrude, outside of specific agencies that can wave the bloody shirt of national security.) A lot of regulation depends on people doing what they are required to do; to take your example, I have seen a dozen or more misbehaving drivers for every one I’ve seen pulled over. (This is a weak analogy for flying, as drivers don’t have to file plans in order to use the roads.)
    I take your point about Execuflight failing on more levels than SK Travel; the latter didn’t have the management that might have told the pilots to shape up when they got sloppy (or diffused responsibility for keeping the pilots up to the mark). I was particularly noting the NTSB observation that the failure to do recordable elements of the checklist had been going on for some time: a long-term data recorder showed only 2 complete and 16 partial control checks in 176 takeoffs. Some of Sylvia’s reports govern point errors, or sheer bad luck; Execuflight was failing on so many levels that the rest of its operations should probably be shut down, but both of these cases were going to cause an accident sooner or later.

  • It seems to me that pilots rely too much on technology the same way drivers of the Teslas that have been involved in (sometimes) fatal crashes do. I’m not a pilot and I don’t like to fly but, to me, passengers aren’t taking their lives in their hands when they fly, they’re putting their lives in someone else’s.
    Thanks for the post

Post a comment:

Your email address will not be published. Required fields are marked *

*
*
*

This site uses Akismet to reduce spam. Learn how your comment data is processed.