NTSB Hearing: Complete transcript Nov. 10, 2015 plane crash - Cleveland 19 News Cleveland, OH

NTSB Hearing: Complete transcript Nov. 10, 2015 plane crash

AKRON, OH (WOIO) -

The National Transportation Safety Board released Tuesday the cause of the Nov. 10, 2015 plane crash. Nine people were killed when the plane went down in Akron just before 3 p.m..

According to the FAA, the 1979 Hawker H25 twin-engine business jet left Dayton-Wright Brothers Airport and was on approach to Akron Fulton International Airport. The Ohio State Highway Patrol says the plane clipped a telephone wire, hit an apartment building on Mogadore Road, then crashed into an embankment behind that building. No one was in the apartment building at the time of the crash.

The victims worked at Pebb Enterprises, a real estate company in Florida. Pebb was scouting locations for shopping malls in Ohio when the plane went down about two miles from the airport. 

READ THE COMPLETE TRANSCRIPT OF THE HEARING BELOW:

Good morning. I would like to call this meeting to order. Welcome to the boardroom of the national transportation safety board. It is my privilege to serve as the chairman of the NTSB. Joining me are -- we meet in an open session to consider the fatal crash of a hawker 700 a into an apartment building just short of the runway 25 at the international airport. Several passengers and the captain lost their lives in the crash. On behalf of my fellow board members and the entire NTSB staff, I like to express my sincere condolences to the family and friends of those who died in this crash. We hope this investigation will prevent such tragedies in the future. The residents of the building were not at home, and while people on the ground face property losses , none was killed or injured. The accident flight was an on-demand charter flight operated by a company under part 135. Many conscientious charter services -- and Federal Aviation Administration inspectors are assigned to each operator to ensure that the regulations and company procedures are being followed. The traveler boards and on-demand charter flight with the assumption that these company protections are in effect. The accident you will hear about today , we found flight crew, FAA, and inspectors fell short. In addition the flight crews briefing was unstructured, inconsistent, and incomplete. As a result there was no shared plan. The disregarded procedures i have mentioned read of like pages from a basic text for preventing accidents. These procedures and the accidents they represent work nor it. This disregard for safety was not confined to the actions of the flight crew, it extended to their employer paid our investigators found organizational factors , scheduling, and other practices that predicated and predated the flight. The captain's test answers merited a failing grade of 40%. Yet it was graded 100%, glossing over deficiencies that could have been corrected. FAA oversight of executive Execuflight -- they implicitly trust that FAA standards, the charter company standard operating procedures, and the professionalism of the pilots will protect them from harm. They have a right to believe these practices -- these protective sessions -- these protections are practiced on every flight. Today tragically we consider the events that took the lives of nine people on board this flight, including both flight crewmembers. Protections built into the system were not applied, and they should have been. We hope by learning from the facts that led to this crash we can recommend changes to prevent such figures in the future. 

Good morning members of the board. I would like to ask the audience that if they haven't already to silence their cell phones. There are two exits to the front of the auditorium, one to the left, and one to the right. Go down the stairs and out the door and follow the only exit signs to depart the facility. You may exit through the rear of the auditorium. Once you have exited, please turn left and follow the sidewalk to the end of the street. If there is an emergency we ask you walk quickly to the nearest exit and make it to the outside following the instructions of the NTSB staff personnel. Seated at the table this morning, starting to my right, the Director of the Office of Aviation Safety, the investigator in charge of this accident, Captain David Lawrence, operations, human performance, and carpet voice recorder. Seated behind the doctor is from the Office of Safety Recommendations. Next is airplane performance, the Director of Office of Research and Engineering, our general counsel, And our Deputy Director of Safety and Communications. Seated behind him is -- to his right, Maintenance Records, next is Meteorology, the writer of this report and finally Brian Murphy, Structures. 



Good morning. On November 10, 2015, a hawker 700 operated type Execuflight crashed during a non-precision instrument approach at the Akron International Airport. The airplane was operated as a part 130 five on-demand charter flight. The airplane was destroyed by impact forces and a postcrash fire. The captain, first officer, and several passengers were fatally injured. The apartment building was destroyed as a result of the airplanes impact. No one on the ground was injured. A flight rules plan was filed. The captain was the pilot monitoring, and had a total time of 6000 hours, and 1000 hours in a hawker 700 and 800 series airplane. The accident occurred on the second day of a planned two-day trip. The accident flight, which was the second flight of the day, departed from Dayton, Ohio for a 40 minute trip. The visibility was one point five miles with an overcast ceiling at 600 feet above the ground. The captain elected to have the first officer flight akron, contrary to the executive flights formal practice of the captain acting on a flight. The flight crew began preparing for a non-precision localized approach to runway two hundred five -- runway 205. The ensuing approach briefing was unstructured, inconsistent, and incomplete. And the approach checklist was not performed. Prior to the final approach fix the first officer began slowing the airplane, likely due to concerns expressed by the captain about another aircraft that they were falling on the approach. The first officer placed the airplane in danger. Although the captain recognize the situation, he never took control of the airplane and allow the first officer to continue. The first officer elected to use flaps 45 on the approach, contrary to the profile that required the airplane to be flown at flaps 25. It was contrary to the training both pilots received a non-precision approaches. The captain did not question first officer's decision. And further he met that he failed to make the flaps -- after configuring the airplane for landing the flight crew was required to accomplish a checklist for procedures. Yet the cockpit voice recorder indicated they never completed the. This slide shows a profile view of the airplanes approach to Akron. The green line represents a constant rate of descent on the final approach to the minimum descent altitude. The black line represents the MDA. The airplane approach fixes 400 feet higher. Because it was on the approach, it was out of position to use a normal descent rate. The airplanes rated descent was twice the rate . The dissent was contrary to procedures for a stable approach. Although the captain recognize the first officer was descending the airplane too fast and the approach was unstable, he did not call for a -- during the approach the captain failed to make any of the required call ups to alert the first officer and the captain allow the first officer to bring the airspeed to fall below the minimum descent altitude. Instead of leveling off the first officer continued to dissent when the captain said keep going. There was no call out on the cockpit voice recorder that indicated the -- indicated they had the airport or runway in sight. About 14 seconds after the airplane descended below the mda, the captain instructor the first officer to level off. As a result of the increased drag due to the improper flaps 45 configuration, the airplane entered into a stalled condition when the first officer attempted arrested dissent. After the captain's instruction to level off, the cockpit voice recorder recorded the first sounds of impact. This is an aerial view of the accident site, with the runway 205 visible in the upper part of the photograph. The airplane crashed 1.8 not a cold miles from the approach -- 1.8 not to cold miles -- 1.8 nauti cal miles from the approach runway. This is a view of the fuselage and engines resting on the embankment behind the apartment building. There were pre-impact structural or system failures. The pilots were properly certificated and there are performance was not impaired by alcohol, drugs, or anything else. Lack of a requirement for flight data -- lack of a requirement for safety management systems for part 135 operators, lack of a hawker and non-precision approach procedure that meets the stabilized approach criteria , lack of a requirement for flight crew training , inaccuracy of data , inadequate FAA surveillance, and inadequate cockpit voice recorder maintenance procedures. I would like to acknowledge everyone who participated in this investigation. The vice chairman was an on-site board member. Board staff was assisted by representatives from the FAA, Execuflight, Honeywell International, and the National Air Traffic Controllers Association. Captain David Lawrence will next discuss operational issues followed by organization all -- by organizational issues. Captain Lawrence...

Good morning, I will discuss the pilot's backgrounds, preflight planning, conduct of the approach, and FAA oversight. Both having previously been terminated from their most recent employer, records indicate the captain's previous employment had been terminated for failure to show up for recurrent training. The first officer had been fired from his previous employer for significant performance deficiencies identified during his simulator training for months prior to being hired. Execuflight was aware of the officers previous deficiencies. 14-cfr part 135 -- pilots conducted their own flight planning and followed an account on a website. The weather forecast called for instrument conditions at the time of arrival. Though the flight requires an auction to be filed , records indicate the crew never filed one. The crew incorrectly calculated their weight by using an inaccurate basic operating late, incorrect passenger and baggage weight, and incorrect fuel weight, contrary to company procedures. Execuflight management was required to ensure the accuracy of the flight plan and the weight and balance prior to doing so. Sop's are widely recognized as an element of safe aviation operation and are an effective countermeasure against operational errors. The crew repeatedly ignored important procedures. As discussed earlier, the flight crew failed to adhere to company policy. These include a failure to include the approach checklist and landing checklist, failure to make the required out suit callouts during the approach, and flew an un-stabilized approach with an unapproved and untrained flap configuration. Execuflight had no means to monitor the daily operations of its airplanes, identify operational deficiencies, such as noncompliance with SOP's, and correct those deficiencies before an accident occurred. In addition to this accident, NTSB has investigated part wanted five accidents in which the operator has lacked the means to monitor routine flight operations. Flight data monitoring systems installed on the aircraft can provide valuable data that can allow an operator to detect trends of noncompliance within procedures. Helicopter emergency and medical service operators are now required to installed such flight data monitoring systems. Operational flight data monitoring programs can provide part 135 operators with objective information regarding the manner in which their pilots conduct flights and a periodic review of detecting and correcting unsafe deviations from company sop's. The staff has proposed recommendations in this area. The nonphysician approach profile that hawker pilots were trained on , once landing was assured. According to interviews, simulator instructors had different interpretations from what landing a shirt met and how the pilots should use that term when deciding to begin their final to send. The staff has proposed recommendation in this area. In addition, non-precision approaches typically require a level off at about 500 feet above the ground. The hawker profile called for a reconfiguration of the airplane. Such a fake -- such a configuration changed at a low altitude. Staff has proposed a recommendation in this area. Execuflight hawker pilots were trained to dissent on a non- -- involving multiple step downs within the final approach fix. Commonly referred to as i've and drive by the red line. Dive and drive approaches have it ended -- have a history of increased risk . The FAA encourages to use of continuous descent approach. A technique that provides a constant rate of descent inside the final approach's -- final approach fix. It approaches a more stable approach. Even though the FAA states is the more safer alternative to dive and drive, they do not require pilots to be trained on the technique. They continue to use dive and drive has means of not -- and staff has proposed recommendation in this area. The principal operations inspector responsible for oversight of the execuflight primarily used scheduled reviews of the company's manual and the occasional line check of the captain to conduct his surveillance of the company. The pilot had not attended ground school or simulator training and was unaware of deficiencies in their training at the parker pilots. The pilot had not conducted a check on any of the operators he saw. Even though inspector guidance states inspections are one of the most effective methods -- as demonstrated by this accident, the oversight system was ineffective in correcting noncompliance smp's and part 135 operators. The faa is now implementing and oversight system . It could help identify operators that failed to comply . The staff has proposed recommendations. This concludes my presentation. The doctor will discuss the organizational issues. 

There were multiple deviations from standard operating procedures that occurred. Deviations were not found on part of the right -- found on part of the flight crew. The pilot records improvement act requires that before allowing an individual to be in service of a pilot, a hiring air carrier must request, receive, and evaluate records from previous employers pertaining to that individual performance of the pilot. In this case both the captain and the first officer have been terminated by their previous employer, however no follow-up was made by executive flight to evaluate the terms of their termination. Staff believe because executive flight did not fully evaluate the information it had concerning the first officer's training difficulties at his previous employer, the company missed an opportunity to determine whether the first officer was capable of operating an airplane safely. Although both pilots had recently completed executive flights management training program, the crew's action during the flight revealed ineffective coordination and inefficient responsibilities, failure to make checklists, failure to call out, and poor pilot briefing. Execuflight's crm training program -- in addition the program included a multiple-choice crm test. The captain's uncorrected test score was documented by the chief pilot as 100%, however on comparison the captain actually received an uncorrected score of 40%. This example highlights the check the box approach by execuflight that minimizes the importance of teamwork, communication, and safety. The investigation also revealed an insufficient rest. -- rest period for the officers that occurred three days before the accident. As a result of improper crew scheduling that did not provide the first officer with adequate rest on the preceding trip, the first officer was likely experiencing fatigue, which may have exacerbated his performance deficiencies during the flight. This event highlights the lack of oversight i company management. In this case the flight that was in exceedances was a captain -- whose role was ensuring compliance. Execuflight's management's casual attitude likely set a poor example for their pilots and sets their regard for operational safety. Execuflight lacked a safety management system, or sms . Sms has been recognized as an effective way to establish and reinforce positive safety culture and identify deviations from sop so they can correct it. In response to key accidents come involving part 21, 191, -- in 2015, the FAA issued a final ruling requiring SMS programs to part 121 carriers. In its final rule, the faa stated its intent in developing part five was to establish a uniform standard that could be extended to other operating parts, including part 135. In the seven years since the first SMS recommendation was made for part 135, and the 20 once -- 20 months since part -- was established -- accident related to organizational culture are preventable. Yet part 135 accidents tight operational safety issues continue to occur. This accident is just one example of many in the past years. Staff believes all part 25 operators would benefit from sms programs, because they would require operators to comply with formal safety methods. Staff has proposed a recommendation in this area. Thank you. The doctor will continue. 

Good morning. I will discuss issues related to the cockpit voice recorder. The accident aircraft was required to be equipped with a 30 minute cockpit voice recorder, but not with a flight data recorder. The accident aircraft was equipped with a tape-based cvr built in 1989. The cvr was overhauled in accordance to the cvr manufacturers instructions. On may 13, 2015, and inspection was performed, including a functional check of the cvr. Although the cvr, shown on the left, experienced heat damage as a result of the accident, the tape, shown here on the right, was undamaged. Despite the lack of damage come of the recorded audio was of poor quality. Meaning that even after extraordinary means were used to remove background noise, the transcript still contains many fragmented or unintelligible conversations. The poor quality was attributed to interference from the aircraft ac electoral generators and significant background noise. After the accident execuflight determined in other cvr installed in a nether hocker aircraft was inoperative, and they replaced it with an overhauled cvr. Most recommendations related to cvr quality issues date back to 2002. Our 2002 recommendation was superseded in 2006 and finally closed eight years later in 2014. The faa issued a safety alert for operators prior to the first flight of the day, and updated faa order 180.1 to provide guidance for FAA maintenance inspectors respectively. The FAA's principal operation inspector was not aware of -- and stated he had no responsibility for cvr oversight. However, no power was available to the aircraft and he could not require the aircraft to be powered, so the cvr was not tested. Generally the inspector comments that the cvr's are not tested with engines running. For the accident aircraft, most of the quality issues would have been detected only if the cvr had been tested with the engines running. Despite the faa's actions, the board continues to receive quality issues. The ongoing investigation of the august 2015 collision revealed a taped-based -- tape-based cvr was not able to save old content before rewriting new content. In February 2014 -- the NTSB has also received inoperative cvr's from other aircraft, such as -- both in 2008. Even the newly recertified boeing 787 had for cvr quality. About at the time of this accident, the FAA was working on updating the standing cvr -- last issued in -- the board provided compounds . On July 20 2, 2016 the FAA released advisory circular 20 -- -- 20-186. As this new advisory circular is not a regulatory, staff is concerned how the ac will be used impact us. Staff believes that having an adequate functional test of the cvr being performed with the engines running, or by reviewing cvr content from an actual flight, the poor quality of the cvr recording may have been detected and corrected. Staff has proposed a recommendation in this area. This concludes our presentation. Staff is ready to answer any questions you may have. Thank you. 

Thank you for your excellent and comprehensive presentations. We will now begin the question and answer segment. 

Good morning, I know oftentimes we say we want our -- we should to have our investigation completed within a year, and you certainly have done that and i want to congratulate you and your team for putting together a very good investigation and doing it in a timely fashion. So thank you. I think the chairman already alluded to this. I go out and give presentations on -- and the title of the presentation is, "our customers getting what they expect?" often we find out they are not getting what they expect. Customers expected a professionally managed aircraft. As we have already laid out, they did not get that. The company, execuflight , had a casual attitude toward standards and compliance. Page 89 of the report says the repeated deviations from sound operational practices identifies missed investigation to identify a culture of complacency. The customers also expect a professionally flown aircraft and they didn't get that either. The crew mismanaged the approach, they had multiple deviations from standard operation procedures, including deviations from the standard federal regulations. There were a litany of failures involved in this accident. In my line of questioning this morning, we will look at the company, the pilots, the very act of congress , the pilot records improvement act of 1976 that was supposed to allow employers have accurate records of pilot previous employment, and finally the regulatory oversight. Let's start with the company. I think the doctor has covered many of the organizational issues. Let's talk about some maintenance related issues that may have nothing to do with the actual causation of the accident but shows a pervasive lack of disregard -- or disregard for doing things right. Captain lawrence, perhaps you would be the one to answer this. I believe the weight and balance document showed the ap you -- the ap u was removed from the aircraft in 2014. If that correct? -- is that correct? 

The APU was removed from that airplane. 

Did the books reflect that it was removed? 

We could not find any record stating that it was removed. And by regulation any major alteration or repair would have to be an entry in the maintenance records. Even a form of 337 . 

There is an approved procedure for removing the APU , but yes maintenance record would have been required. 

And they were not that we could find? Once it was finally replaced in 2015, the weight and balance , were those amended? so when it was removed in December, they reflected a 300 pound loss from the APU. But when they reinstalled the APU, did the weight and balance records reflect that? 

The weight and balance records that were found on the aircraft -- even though we found the apu in the records. 

Is that not legal to have your weight and balance be correct. 

No, it is not, there is some conflicting testimony as to whether or not the first officer was scheduled legally for a particular flight. On a previous flight a couple of days before this crash, he was supposed to have had 10 hours of rest period. Our records show he only had seven hours 45 minutes of rest. 

Yes, when we first did the analysis we used the flight logs that Execuflight had provided to us, which reflected and on-duty time for the first officer of 3 p.m. Prior to that day. In this case he flew two flights, and a second flight was an overnight flight to mexico. At the end of that overnight flight , he had seven hours 45 minutes of rest according to those flight loss -- flight logs. We had conflicting information coming and where the president of the company stated the first officer did not go on duty until 5:15 that day, which gave him absolutely 10 -- which gave him 10 hours of rest. There is evidence that provides contradictory information to what the president has said. 

I think you have hotel receipts that shows they checked out of that hotel . 

It was 1200 9 p.m. -- it was 12:09 p.m. 

We don't normally takes one testimony unless it was an investigative hearing. We have sworn testimony from the captain who flew with the first officer , and we have sworn testimony from the president of the company and they are showing conflicting things. It probably means one of two things, somebody's memory isn't correct and somebody is not being truthful. I will come back to more issues and get back to the pilot in the next round of questions. 

Thank you and good morning. In the chairman's opening remarks he talked about the crew research management training , a rather cavalier approach to the training. Documenting completion rates that were 30%, 100%. The NTSB courses had a long history of recommending crew research management. In fact previous toward members were instrumental in developing and implementing crew research management. In this case it appears the crew resource management was not very effective training. -- effective. Training was not complete. Recommendations for training with crew members together were not implemented. In this particular case the captain was very reluctant to step in. He had observed the opening getting slow. Of he had won the first officer against stalling it. He did not take over or exercise as command authority. Does the CRM address that? 

The training would have addressed that. It was technically in the requirements, which was covered in the pratt -- covered in the powerpoint presentation. The questions the captain had missed, we saw deficiencies in terms of the captain's understandings of the responsibility and authorities. We saw deficiencies in flight deck management. Those were the questions that were missed. 

I guess it wasn't questioning in the particular cases of this accident. The captain was the pilot monitoring, the first officer was the pilot flying. Checklists were incomplete. Two captains make poor pilot monitoring? -- do captains make poor pilot monitoring? 

I believe the study you may be referring to is a 1994 study on accidents related to crew -- to crewed deficiencies or performance issues. In that study what was found was that there was a higher percentage of accidents that the pilot flying was actually the captain. In this case we don't necessarily think the study would apply here, because the caption was pilot monitoring. It should also be mentioned this is why you have crm training. This is what has been recommended . 

Let me move to safety management systems. Safety management systems have been really acknowledged as part of the tools that have led to the real dramatic improvement in part 121 commercial airline flying. But they have not been applied to are required in part 135. What would a safety management system have been for this particular operator and accident? 

The safety management system gives the company structure to actively manage the safety. In this case, implementing the components of safety policy and making sure there are documents, there are objectives that are clearly defined for the entire company would have set the stage for the entire company in terms of their commitment to safety. An sms provides a to cool for safety risk management reporting. If a pilot may have had an issue , such as procedures weren't being followed, there would have been a nap and new -- then an avenue to take that to company management. -- there would have been an avenue to take that to company management. Maybe advocating following sop's . Flight data monitoring is one way to do that. In addition to the safety aspect there is the safety culture in terms of the company. All of these components are implemented and the company could have had an effect on the issue we saw here, one of the many issues. 

Flight data monitoring is one of the sources of information for safety assurance, as well as risk assessment. Would not having a flight data recorder on board the aircraft , how would safety assurance be accomplished without data? 

There are multiple ways to accomplish safety assurance and continual assessment of data. Another way is getting feedback from pilots on your flight. In a way that is not implemented over require a recorder in the cockpit. 

I will yield the rest of my time for this round. 

To begin i would like to thank staff for their excellent work on this investigation and the report. This is my first on scene experience , and i appreciated all the NTSB staff and FAA staff for taking the time to help me learn more about part 135 operations. I was impressed with the professionalism and compassion. Coming from a surface transportation background, i equate part 135 operations to limousines or taxis in the sky. The people who hire these operators do so with the expectation that they are going to be on par with a part 121 air carrier operation. Tragically that is not always the situation. I would like to start my questions by asking about part 135 operations to help us and the public understand better the sense and the scope of these issues on safety. First question is to you, how many part 135 operators are there in this country? 

Currently there are 2061 operators flying part 135, that would include 11,231 aircraft. That also includes helicopters and airplanes. 

Could you provide me a rough breakdown of flight hours both on-demand and scheduled hours ? 

Part 135 on-demand is about 300,000 -- scheduled is 300,000 and on-demand is 3.7 million. Almost 4 million part 135 flights are flown each year. 

How many hawkers are in service? 

The number flying 135 certificates are -- there are 853 registered in the united states under part 91. And in our service worldwide there are 3058. 

Thank you. Of those in service here in the u.s. , how many of those are the different types? 700 a, 700 a1? 

94 of those 272. 

Thank you. How many of them operate under part 135? i know you mentioned that in the course of your answer? 

Currently there are 272 hawkers. 

And the others are under part 191? I have some questions for you about flight data monitoring. Can you tell us why you think the new proposed recommendations about flight data monitoring are so important? 

Certainly. One of the challenges the faa has in their oversight of part 135 on-demand is just the nature of the business. They don't know when it is going to go out. Since it is on-demand the faa has a hard time trying to do route inspections, at inspections. Operators have a hard time understanding what actually is going on with the operation outside the training environment. When the airplane leaves the base and flying revenue flights, unless somebody is writing on the jump seat or observing there is no way to understand what has been done on a day-to-day basis with the operations. Flight data monitoring program would be able to take that data in on a regular basis, analyze that, and identify any deficiencies , such as noncompliance with sop's. The operator can then go into the training procedures and adjust those indication elements they found in the operation. 

The sort of data, if there was a flight data monitoring program, that would raise red flags would be unstable lysed approaches or not following sop's. Are there any other types of information that would help monitor the data? 

There is a litany of elements that they could be looking at. Maybe power settings or temperatures that are in exceedances recommended -- exceedance of recommended takeoff procedure. If flight operations quality insurance is a more structured program with the airlines, but it is the same principle of collecting data. 

Thank you captain. Mr. Marcus? Would you identify some examples that illustrate how a program like this has been used to identify safety issue? 

We recently had a board meeting about an accident that occurred in Bedford, Massachusetts. The pilots had not removed the locks before the takeoff. As a result the played -- result the plane was not able to take off, crashed, and killed everybody on board. That is something that should have been readily apparent to the pilots before they started their takeoff . For a second or two they moved the controls to a full range of motion . We issued a recommendation to the National Business Aircraft Association, which has been working with some of their members who have flight data monitoring programs. We ask them to go through and analyze their data to see whether or not the lack of preflight checks was a single crew who fail to do it or whether it was a systemwide problem. A year after we issue did a month ago, they send us a copy of the report and found that only 20% of their flights that they reviewed was there a preflight check done. That is an example of illustrating a problem people are not aware of when you have the data and can do the data -- do the analysis. 

Thank you. In light of what Captain Lawrence said about the challenges in doing this type of work, flight data monitoring seems essential. 

Yhank you. I have a couple of areas i would like to cover. What did you say about the studies and what they showed? 

The data that was shown in the study showed there was a higher percentage of captains operating as pilots flying in the accidents. In this case because we have the captain here , we wouldn't want to make the extension about the results of that study. 

Were be able to make a comparison as to how much the pilot in command is flying versus -- can we get some exposure number to see the accidents were likely to be -- is that because they are more likely to be flying then a second in command? 

In the study they had actually taken out cases where the captain may have taken over some aspect like that. 

Thank you. What I would like to go into at a high-level is data monitoring process flight data recording. I would like to give an overview of what the flight data recorders issue was. Can anybody give me a high-level overview of that? 

I can talk about the flight data recorders, they are not required right now. The recommendation the staff proposed mirrors the flight data monitoring program that is required within the emergency helicopter services. The regulations say these helicopters have to have the recorder in there, but the FAA didn't go as far as requiring any type of program that required an analysis of that data. Our proposed recommendations aren't just to put the quarter in the 135 demand. But also a program that can actually analyze it. I would defer to Mr. Marcus. 

To what extent 135 operators are now required to have flight data recorders, is it only the larger ones? what is the story? 

I can answer that. The flight data recorders are required generally for aircraft over 10 or more seats within 135. 

Of it is less than 10 seats it is not required to have a flight data recorder. Same question on a flight data monitoring, to at extent is there any flight data monitoring requirement for part 135 operators? 

As far as 135 it is not required. The only flight data monitoring system to be installed is on the hems . 

Help me understand a flight data monitoring program, it would not necessarily require a flight data recorder. Is that correct? 

Flight data monitoring, that particular type of recorder would not have the crash were the protection that a flight data recorder would have. And those governing regulations. An operational recorder wouldn't necessarily have that type of capability to survive a crash. It would have data that would have survived the crash and could be used in an analysis . 

I think it is important to point out there is no flight data monitoring program that is required in any operation. We have recommendations from the accident near Buffalo to make a program apply to everybody. Nobody is required to do it and the FAA's motivation is they can make it to a imputed of system. They have maintained in all of the recommendations that they require a program for any type of operation, they can make at the nonpunitive reporting part of it. 

To what extent in this report are we recommending changes to flight data recorders and then changes with respect to flight data monitoring? 

We are not making any recommendations for flight data recorders . Cockpit voice recorders are a different thing. 

I was very impressed we got as much information without a flight data recorder, why are we not recommending flight data recorders be used in this industry? 

I think it is important to realize we have a recommendation that is currently open with the faa to require an image recorder. Image recorders are less expensive. And to both purchase and install a full flight data system, they represent an approach for smaller types of aircraft, which is this one in this accident, where the economic burden for implementing fdr would be large. We have had access -- accidents such as the accident involving an alaska state trooper. We were able to obtain fdr -like data from the instruments. The recommendation to the FAA to require recorders in this type of aircraft is currently open. That is the one that would apply here. 

Thank you. And to what extent are we making recommendations regarding flight data monitoring? 

The number two recommendation in the draft report is for FAA -- for the FAA to restructure their program for all part 135 operators. 

I will resume with my second round. Thank you very much. 

Captain Lawrence, I will ask this question to you and Dr. If you have anything to fill in, flight required new a higher pilots to sign a two-year employment contract in a strange for which they would pay for the training. If a pilot left voluntarily or was terminated, they would have to reimburse execuflight, which could cost into the tens of thousands of dollars, probably at least $30,000 to go through a full course, so is it possible that this incentive, this financial incentive hanging out there could put somebody in the decision of getting the job done at all costs for fear of termination? Capt. Lawrence, your opinion -- Captain Lawrence, your opinion. 

I can relate to what we found in the investigation. We did not have any evidence that the pilots were flying under some type of financial pressure. Just a clarification on the training contract. Execuflight typically would send the pilots through the training and pay for their training and their hiring. The employment was conditional upon their successful completion of the program, but we did not see any pressure from the financial contract thereunder. 

Yes, but even after, the employment was conditional upon passing it, but if they left after they had been trained, they would have to reimburse the company. Just because they passed the training and got hired does not necessarily provide the reinsurance they will not have to pay things back. My concern will be with the employment contract like this, people do not want to lose their job so they will do things to get the job done so to speak, even though it may not be the best course of action. I hear what you are saying. We don't see any evidence of that here. Just another thing i saw related to the organizational culture of Execuflight. Now let me move to the pilots . I am going to read through a few bullet points that are listed in the report for what the pilots did or did not do. The approach briefing was not completed. The approach checklist was not completed. Aircraft configuration changes were made without required callouts. Instead of flying the flaps at 25, they can figure it to fly at 42. -- they configured it to fly at 42. The captain did not make numerous required callouts, including checklist complete, call out for the landing checklist, the final call out, reaching 1000 feet, 500 feet, the minimums call out were not made. The approach was on stabilized -- was unstabilized. The goods in the mba without the runway insight. I have talked about the company. Now we are looking at the pilots. I it is a regulation you are not to exceed 250 below 10. How long before they slowed to 250 ? i could not find that. 

I don't think we actually determined when they slowed to 250. When they were only approach on the localizer, they were able to get down to 200. 

Iowa looking at radar derived -- I am looking at radar derived here air speeds. It looks like 20 to 30 seconds they were exceeding the 250 airspeed below 10,000 feet. 

Thank you. They went from being too fast to to o slow. They were below the entire approach. Is that true? 124 knots . 

Yes, that is correct. 

What speed with a fine for the final approach inbound? was it continuously below that value? 

They hit 109 knots. In the descent , they got to 118 knots , but they stay below 124. 

At 109 knots at the final approach, it was 124 knots . 

At that point in time, they should have been at flaps 25 plus 20. 

They should have been at 144 knots at the final approach, and they are at 109 knots . The state below the value throughout the entire approach . Pilots at Execuflight -- I looked at Execuflight 's webpage last night. They said aircraft safety is our top priority. 13.5 establishes strict safety maintenance and operation standards for charter aircraft operations, and i agree that part 135 does establish those standards, but if you do not stick to them, if you do not follow them, they mean nothing. This is an organization that does not pay any attention to the maintenance. We saw the maintenance records were not accurate with regards to the ap u being installed. They did not look into why the pilot was fired from his previous employer. They did not ensure that the crews were operating according to standards and we saw that the flight deck was not following procedures. This organization whether we are talking about the cockpit level or the organizational level, it was infested with sloppiness . Thank you. 

Thank you. 

Thank you, Mr. Chairman. In the discussion earlier with Captain Lawrence, we talked about the dive and drive approach. That approach factors into the Birmingham, Alabama, UPS accident, and to some extent, some aspects were in the 214 accident. Can you describe what are the disadvantages and challenges of the dive and drive approach? 

Certainly. These challenges and problems are actually outline in the advisory circular that was put out. The problem is from the final approach to get down to the nda, you are descending at a greater descent rate. You have a chance at getting more unstable and increasing your recommended descent rate. You have to level off so there is configuration changes and engine thrust changes. There is a lot of things going on with the airplane on a dive and drive. Very when you get to the final approach fema you ar , you are getting down to the nda. 

In this case, there is no vertical guidance so the vertical guidance is made up approximately by choosing a descent rate? 

Certainly. There is a chart in the advisory circular that says based on your godspeed, here is what the descent would equate to. There is also means to develop vertical guidance internally within the airplane. You can approach similar to what ups had in that particular accident. In this case, they did not have that capability. The airplane did not have those kind of instruments. Since we have done a 750 foot per minute descent down, that would approximate a three degree glide path. 

If the approach cannot be created , it has to be published, correct? 

You are correct. There are approaches that have vnab on there. It is not what you are flying , but it is a guide for a three degree glide path. This airplane did not have the capability. 

In fact, a loss of GPS would have basically provided him with the information necessary to create a constant descent angle. Head up displays also is some cases provide the ability to have a three degree are a program selected flight path. In this airport we had an approach for 25 a localizer approach. There was no guidance. How prevalent are the approach is nowadays using it for approaches? 

I do not have a particular number at the present . 

I have a slide from the faa dated june 2016, and it looks like about 3700 airports in the u.s. Have GPS with vertical guidance approaches. 

All of that vdab or lp v? 

lpv's. 

Which are roughly equivalent to the approach from category one? 

That is correct. 

That would have brought them down to 200 feet approximately. 

That is correct. 

Thank you. I think i will you the rest of my. 

Thank you. 

I would like to follow a on member Weener -- up on member Weener's proposal. As a primary means of conducting non-precision approaches, we had a recommendation that was closed out. It was closed unacceptable to the FAA, that was a1476. It was closed unacceptable in February of 2015. We stated we believe that this dive and drive maneuver should be prohibited. Is that correct, mr. Marcus? 

Yes, that is correct. The recommendation a 1476 was to basically require that the use a tdfa for all of their approaches. One of the interesting lessons from this point is somebody was a 135 qualify pilot and was never instructed on how to do a cf dfa. With the knowledge we gain from this investigation, not all pilot had instruction on that technique. We cannot ask them to require a flying technique until pilot learn how to do it and are taught to do it and that is the reason for the new recommendation. 

Can you explain how the new recommendation is different from a 1476 just so we are clear on that? 

The new recommendation is to require that the training program for pilots, which the FAA needs to review and approve for each individual carrier, that one of the elements in the required pilot training is that i was be trained on how to do a non-position cdfa. In addition to being trained on the technique, they be trained that it is a preferred method to follow. 

As you know, i am interested in what recommendation recipient will need to do to satisfy recommendation so when you say the work requires in the new recommendation, will they need to undergo a new rulemaking to meet intent of this recommendation? 

I am not a lawyer, but my understanding is that they would not need to change the code of federal regulations. The existing regulations already require that operator's training program or its pilots we review be reviewed and approved by the FAA. They established guys guidance. What they would be doing to respond to this recommendation, they would be making it so their inspectors would review the training programs to make sure the cdfa's were part of the new required training and the training needed that it is a preferred method to follow. That can be done without a coat of federal regulations. It is a change in what the inspector will find acceptable when he approves the training program. 

Yhank you. I think that is an important point that we are not asking for a change in rulemaking, but this is a change in this type of what the inspectors looking for, which potentially improves safety. Thank you, mr. Marcus. Dr. Silva, could you explain to us in practical terms how an operator of this size like Execuflight could have had an effective sms program or how they may have provided for an effective crm program, which were deficient in this accident? 

Yes. To answer the first question, i will start with sms . The basics behind sms are pretty integral in terms of any system that a company should pretty much already be doing. What sms is is a restructuring of any programs or initiatives they may have already and really putting safety at the forefront see you can actively manage it. In this case, the policy is pretty straightforward, making sure the company knows safety is the number one priority and they will hold accountable to that. Risk assessment and risk management. Those are looking into reporting. In this case, Execuflight said that any issues , pilots would not come directly to the president or the chief pilot with any issues. You can enforce some kind of anonymous reporting. These are pretty simple tactics that can be used in any size organization. You just have to scale the message you used to accomplish the goals , but the message behind it is not new, and it is something you should already be doing, whether it is a one aircraft single pilot operation or a larger operation. 

Thank you, Dr. Silva. I like what you said in response to member Weener's response earlier that it is active rather than reactive. MS and these other safety measures are not onerous, but they are doable. We recognize part 135 operators are businesses, but your answer demonstrate the safety measures are practical and possible and not onerous. Thank you. I have a little bit of time left. I will quickly try to ask this question. Thank you for giving me the opportunity to go to the lab and meet with you and listen to the recording, which i thought was very useful in this case. Can you please explain why this airplane has a 30 minute rather than a two-hour cvr? 

Yes. For aircraft that have, a generally for a cockpit voice recorder, the cardinal regulation for 135 is six more or more seats requires it. That is a 30 minute regulation. There are some regulations beyond that that required two hours that do not apply to this aircraft. 

Thank you. My time is up, so I will continue later. 

Thank you, vice-chairman. I would like to ask about the fact that there was no go around command for the pilot in command. Do we have a reason why the pilot in command thing is a that situation, which was apparently getting worse? why in that circumstance he did not order the go around or over do it himself? 

We cannot get into the head of the pilot to find out what he was taking at the time, but they were trained to do the arounds -- go arounds. There were multiple opportunities that the staff believes the cap it should have gone around. 

Do we have enough information to know why he missed all of these callouts? is that consistent with his past record? I've been to figure out what is going on here. 

We don't have information on his past record based on the evidence we have, but when it comes to procedural noncompliance, generally, when you see noncompliance like this, there is a couple of aspects that are apparent. One is that there is motivation. They wanted to get the aircraft on the ground. Typically, from their perspective, they may have a high probability of success. In that case, the captain may have overestimated their ability, may have done this in the past without negative consequences. These are all things that go into procedural noncompliance. The final aspect is the absence of fear pressure and negative reaction, so maybe he was never admonished for this kind of behavior in the past, which is essentially reinforcement in this case. 

Thank you. Will be aware of any time pressures that they were trying to get on the ground sooner rather than later because of some meeting? 

We don't have any evidence of that. 

Let me turn to the continuous descent and final approach. Given the equipment in this airplane, tell me how they would do that . They would come to the final approach a look at the table and see what they need to do to have a continuous descent approach? 

Exactly. That is given on the approach chart , the speed that they would need. That was available to them on the chart they had. 

But they were not have had any electric indication. They would have to indication whether that was keeping them all the three degree approach. 

It is an approximation, but it is based on ground speed. In his airplane, there was not any type of electronic means to monitor the glide path. 

To what extent was their training offered? to what extent did they receive continuous descent approach? 

The short answer is they did not. We asked to see an instructor. A couple of them said they taught cdfa a little bit, but they had no formal instruction. When we asked them what was a cdfa , we got various variations of that. 

Thank you. I have no further questions at this time. Anybody else have any further questions?

We have talked about each of the layers of the system. We have looked at the organization, the flight crew. Now i want to talk about the regulatory oversight. This is the principal operations inspector assigned to Execuflight. He had a total of 16 operators to provide oversight for. Funding limitations prevented him from attending the simulator training in Dallas . He noticed, he stated Execuflight was "a very good operator." i think our discussion this morning is showing they were missing some valuable things. He seems not aware that the internal audit they were supposed that it was a year overdue. What can we say about the FAA oversight? how can one person provide surveillance over 16 different operators and doing it well? 

When we talked about the surveillance activities with Execuflight , the investigation found that he was essentially relying on the occasional check of manual when he showed up and the occasional part 135 299 line check, which is a checking flight. He would use the occasional review of the manuals and is occasional part 299 line checks to do his surveillance. He had 16 certificates. 14 of those were part 135 certificates. We also asked him if he had any enm route is veterans on any of the -- rout e is factions on any of the 1 -- route inspections on any of the part 135. 

We have seen is not stand, and bad things happen. Surveillance involves more than checking boxes to make sure things are in place. You have to measure they are doing those things. Anybody could have a manual and say we are doing these things and having the forms filled out. You have to provide the safety assurance aspect to make sure they are doing them. There is a proposed finding that has been changed since the revisions, with the revisions. I will read it to you right now since i am not sure i totally understand it. Is says the ntsb concludes the faa failed to provide adequate oversight of Execuflight 's pilot training, and as a result, deficiencies in their training. We have not talked about any deficiencies in the training itself, so what are we talking about when we say that? 

The training that occurs is Execuflight 's training program. Even though they are contracting with another operator to provide the simulators. The training is execuflight 's. The have oversight authority over that particular training. There are multiple areas , for instance, landing . There was no definition of that and the instructors were giving rather wide array of different definitions of what landing assured was. That is something they could have taken a look at and asked how are you training that, and keep more consistent training. 

You and I flew for the same company, and the way that -- was landing was assured, we ascended to flat settings, and no one ever questioned what that meant, even in our airline. Why are we digging the FAA on this particular aspect? 

I agree with you, but i think it is the wide array of the definition of landing assured that we got from the instructors. So say the final flaps that he was to be done sometime during the approach all the way to when instructors saying landing assured met when the wheels -- meant when the wheels touched down. It was such a wide definition that there is no consistency on what it meant. 

Isn't it true that the idea of flying the approach at flaps 25 until landing assured, is not with the aircraft manufacturer recommended? That is that not what the aircraft manufacturer recommended? 

That was for a single engine approach and then landing assured would occur for a single engine operations. It kind of morphed over time or the trainers used that as a standard for all non-precision approaches. The manufacturer defined that for a single engine approach. 

OK. We get to that finding, I am not sure I will support it but i have to think more about it, and hopefully we will have a break between now and then so I can more about it because I'm not convinced the FAA should have done much more because I don't know that is any deficiencies in training other than what you are seeing is landing assured , an that training was provided through all of the hocker pilots, whether they were at simuflight or no matter. I suspect that was the same terminology used there. And my right? -- am I right? 

We know it was used for the 700 and 800 aircraft. 

Universally. Not just simuflight . 

It has typically been used on other aircraft as well. 

Let me switch gears. The pilot records improvement act. It was passed in 1996 to keep pilots who have had a questionable history from being hired or really to make sure that when somebody hires somebody, they know what his or her training history is. Here, the captain had prior FAA enforcement action read he was terminated by his previous employer. The first officer terminated because he was having training difficulties. Why did Execuflight not know of these training deficiencies or these performance deficiencies at their previous employers? 

For the captain, Execuflight did not get the information as far as his termination why the captain was terminated. He was terminated because he did not show up to recurrent training. That is not something that really needed to be sent to the other operator because it had nothing to do with performance of the pilot. It was just an employment act. First officer was different. They had significant documentation on his deficiencies. When we asked the president of the company about the first officer and they were aware of the training deficiencies, he said something paraphrasing that he was hiring him as a second in command so he did not hone in on it . 

But the present company did have access to the fact that this guy's training record at sky king was not good at all. 

That is correct. 

They hired him anyway. I have one more question. I can wrap it up now. I have asked this question when i met with staff, and i want to hear the answer to it now. On page nine of the report and the cockpit voice recorder, to cap and points out, you are going 120. You cannot decrease in your speed. The first officer replied, no, how did you get 120? i am wondering if perhaps there may have been a discrepancy with the first officer's airspeed. And we had any indication that the airspeed indicator on either side was erroneous? 

I will go ahead and answer that from the maintenance standpoint in the records we saw. No we saw no writeups. It was inspected september 1, 2015, with no discrepancies at that time. We saw nothing in the records indicating it. 

Thank you. I have no further questions. 

Thank you. Any further questions? 

I have just a follow-up question related to the cockpit voice recorder. It is really a question for the doctor. The report talks about being a self test . The principal avionics inspector talked about putting earphones in and listening to the audio. Is the self test an end to end test, or do you have to do that with plugging in the earphones and listening? or is any of these really end out end checks -- to end checks? 

There are two recommended by the manufacturer. What they are required to do on your checklist before the engines are started is a pushbutton test. It is intended to check the functionality of the cvr. It is like a five second test. It is a pushbutton test. The emotional test done by maintenance -- the functional test done by maintenance four months prior is a more in-depth test. It would include a listening, a plugging in. That is how the manufacturer recommends it. 

It includes writing on tape and listening to the tape as well? is that correct? 

Not to imply a download, when but when you plug in, you are listening to what is recorded, and that is part of the functionality and design. 

The problem in this case was a noisy air-conditioning generator. Without running the engines, that was not to be discovered. 

That is correct. That is what staff believes. 

Do we have any recommendations or findings related to the necessity to actually do a flight- like check? 

In the recommendation we are making, it is not that prescrip tive. We say you have written 20-186, with the board commented on in december, and we would like you to look at the circumstances of this accident, this cvr and verify that the provisions in the ac would have caught the problem. Therefore, we take a higher level view of it. 

That might require actually powering the aircraft and running engines? 

It might. We don't really go there in the report in our findings or recommendation. 

Thank you. No further. 

Thank you. Any further questions? 

Yes. Thank you, chairman. As staff already knows, expanding recorder use is on the ntsb's most wanted list and one of my advocacy areas so I would like to ask some additional questions about the recorder. We know that getting information from the cvr is a labor-intensive and careful process anyway, but it is probably made all the harder when the information is of poor quality. Could you very briefly explain what you needed to do to the data in order to obtain as much information as you were able to obtain? 

Certainly. Essentially, the application of audio filters was done. The application of numerous audio filters was done, which is a lossable process, so it degrades the quality while getting us more out of the CVR and more sounds, but it also has another side effect of cutting out some of the information at a frequency level, so it makes it harder to hear as you heard when you listened to the CBR. 

Thank you, but i think it is undoubted that the information that was found in the CVR was important to the investigation. Could you provide some examples of facts or conclusions that we would not have been able to draw if the airplane CVR had not been able to reveal this type of data? 

Certainly, the information concerning the approach and what the pilots where discussing during the approach would be very difficult to ascertain. Certainly even with the 120 knots and other details on the CVR, that would not have been available. Also, just the setup of the approach, the callouts, those types of things that we were looking for and did not find certainly were very significant. Which crew member was flying, which one was monitoring? those types of things were very helpful in having the CVR. 

Thank you. Thank you again for your work on this investigation. I think we can all recognize that recorders are so important, but I don't think people don't always appreciate, i did not always appreciate the labor-intensive process it takes to get that information and the importance of what it can reveal, so thank you. I yield the rest of my time. 

I have no further questions at this time. We will take a brief break and resume at 11: 25? 

Can we take our seats? We are going to resume momentarily. We are back in session. We will now commence with the liberation. Please read the proposed findings. 

As a result of this investigation, staff proposes 28 findings. 1, the flight crew is properly certificated and qualified in accordance with regular organizations. No evidence was found at the flight crew's performance was affected by toxins, alcohol, or other drugs or medical conditions. Two, postaccident examination of the airplane found no evidence of any pre-impact structural, engine, or system failures. Three, the air traffic controllers handling of the flight was not a factor in this accident. Four, as a result of the flight crew's failure to complete the approach briefing and approach checklist as for standard operating procedures, the captain and first officer did not have a shared understanding of how the approach was to be conducted. Fi ve, before the airplane reached the final approach when the first officer reduced airspeed and placed the airplane in danger of encountering the stall, the captain should have taken control of the airplane or call for a missed approach, but he did not himself. Six, when the airplane reached the minimum descent altitude, the approach was not stabilized. The captain should have called for a missed approach according to standard operating procedures, but he did not do so. Seven, with attempting to address the airplane's dissent, the first officer did not appropriate manage pitch and thrust control inputs to counter the increased drag on the 45 degrees flap setting, which resulted in an aerodynamic stall. Eight, the captain's failure to enforce adherence to standard operating procedures and his mismanagement of the approach place the airplane in an unsafe situation that ultimately resulted in the loss of control. Nine, the impact forces of the accident were survivable for some occupants, but the immediate and rapidly spreading postcrash fire likely precluded the possibility of escape. 10, operational flight data monitoring programs could provide 14 regulations part 135 operators with objective information regarding the manner in which their pilots conduct flight. They periodically view such information, could assist operators in detecting unsafe deviations from company standard operating procedures. 11, because executive execuflight did not evaluate the information it had regarding officers training at previous employer, the company missed an opportunity to determine if the first officer was capable of operating its airplane safely. 12, the flight crew did not demonstrate effective crew resource management during the accident flight. 13, deficiencies in execuflight 's crew resource management crm training program including the cursory review of crm topics, a lack of appropriate evaluation of crm examinations , and the lack of continual reinforcement of crm principles resulted in the flight crew receiving inadequate crm training. 14, although the flight crew used multiple deviations from standard operating procedures concerning weight and balance on each flight of the trip like we did not contribute to the accident. The deviations represent a pattern of routine disregard for sop. 15, execuflight management had multiple opportunities to identify and correct crews routine disregard for procedures, but failed to do so. 16, execuflight 's casual attitude towards compliance with standards illustrates a disregard for operational safety, an attitude that likely led is pilots to believe the that strict adherence was not required. 17, safety management system programs can benefit all 14 regulations part 135 operators because they require the operators to incorporate formal system safety methods into the internal oversight programs. 18, the captain's degraded performance during the flight was consistent with the effects of fa tigue. 19, as a result of disruption, and execuflight flight crew scheduling that did not provide him with adequate rest for his preceding trip, he was likely experiencing fatigue which may have exacerbated his performance deficiencies during the accident. 20. The non-precision approach procedure that pilots are trained on does not meet the stabilized approach criteria published . 21. 700 and 800 series pilots are receiving inconsistent training regarding the meeting of landing a sure that may conflict with the language of 14 code of federal regulations 91.175 c one. 22. Despite the guidance in advisory circle 120-10 eight, many operators do not train their flight clues how to perform a continuous dissent final approach the dfa and use ac dfa whenever possible. Flights failed to ensure the correct weight and balance information was on board the airplane and enter into the company's weight and balance software which resulted in the flight crew underestimating the airplane's weight on each flight of the two day trip. 24. The federal aviation administration failed to provide adequate oversight of flights pilot training and as a result deficiencies in that training were not identified. 25. This accident shows the federal aviation administration guidance for principal operations inspectors regarding conducting 14 code of federal regulations -- flights other than revenue service is not effective in identifying pilots who are not complying with standard operating procedures. 26. This accident illustrates that the federal aviation administration's surveillance priority index was ineffective in identifying 14 code of federal regulations part 135 operators in need of increased surveillance. 27. The implementation of the safety assertions -- assurance system -- use oversight procedures to identify and correct problems with failures of 14 code of federal regulations part 135 operators to use standard operating procedures. 28. At an adequate functional test of the cockpit voice recorder installed on the airplane had been performed with the engines running or by downloading and reviewing content from an actual flight the poor quality of the recording may have been detected and corrected. 

Thank you. We have some amendments to the findings. 

Thank you, chairman heart. I would like to refer to find a number 19. Sean has passed out a paper copy that should be on your desk. Disregard anything that you may have gotten last evening by e-mail. On 19 i would like to modify it as follows. This is my motion. I propose that we amend finding 19 to read as a result of circadian disruption and executive flights in proper crew scheduling that did not provide the first officer with adequate rest for his preceding trip the first officer was likely experiencing fatigue. I'm going to strike where it says which may have exacerbated his performance deficiencies during the flight. And replaced with however the extent to which fatigue contributed to his deficient performance could not be determined. That is my motion, mr. Chairman. 

Is there a second? 

The motion has been made and seconded. I would ask the staff how it feels about this amendment. 

Staff concurs. 

The motion has been made and seconded. All in favor of amending finding number 19 signal with a hand. I understand you have another amendment. 

I'm still troubled by the proposed finding for finding number 24. It currently reads the federal administration failed to provide adequate oversight over pilot training and as a result deficiencies in that training were not identified. I may be out of order. I do have a motion and it might be a little different than what I discussed during the break but we will see where it goes. This is my motion. The federal aviation administration provide adequate oversight of executive flights try -- pilot training maintenance and operations. And i will propose to strike the rest of that sentence that says and as a result deficiencies in that training were not identified. That is my motion and i will be glad if i get a second to explain why I am proposing that. 

Thank you. Is there a second to the motion? made and seconded. We go to discussion. 

Thank you. In the discussion we had in the open session i was not convinced that there were true deficiencies in the training program . If staff could convince me otherwise i would be glad to entertain that. I do think we did find evidence that the faa in their crm training were not scoring that as they should have. Minimum grade for passing should be 80% correctable to 100. One pilot made only a 40%. On one of them i'm not sure -- the other was uncorrected to 70% and i'm not sure either of those were fully correct to 100%. There were deficiencies with the maintenance. The ap you was supposedly removed in december. Maintenance records did not accurately reflect that. There were deficiencies in the weight and balance of the airplane. Furthermore the operations itself. Had the faa done more than just -- if the operations inspector had gone out and done checks and regular line service we pointed out that not an effective way of finding out what really happens on the line. I think all together that will the case that the flight had poor maintenance, training, and operations and furthermore the faa is there to provide oversight. I do not believe they provided adequate oversight of those issues. That would be my motion. 

Thank you. Let me read it again. The federal administration failed to provide adequate oversight of maintenance and operations. Is that your proposed finding? 

That is correct. I'm just looking at the probable cause first. That could work. If i'm looking at the pc now it does not say maintenance. I'm willing to take that off the table. 

That was my next question. Does the staff have any comment on that. 

We certainly agree the herpes of that finding is to identify the faa failed to provide adequate oversight. Pilot training maintenance and operations. We are good with that as the finding. The maintenance action really wasn't causal to the accident. It's not in the probable cause. We are happy with that. 

I agree with your assessment. Thank you. 

Any comments from any of the members yet go the motion has been seconded. 

I do have a question. To be clear you are proposing that everything is struck after pilot training and operation is added. 

That's correct and I will be glad to restate the motion if you like. My amendment is the following. The Federal Aviation Administration failed to provide adequate oversight of pilot training maintenance and operations. That's the motion. 

The motion has been made and seconded to amend finding number 24. All those in favor signal with a hand. The vote is in favor of adopting finding number 24 as amended. Is there a motion to adopt all of the findings as amended. Is there a second. The motion has been made and seconded to adopt the findings. The vote is in favor of adopting the findings as amended. Please read the proposed probable cause. 

Staff proposes the following probable cause. The probable cause of this accident is the flight crews mismanagement of the approach and multiple deviations from company standard operating procedure which placed the airplane in an unsafe situation and lead to an unstable eyes to approach without visual contract with the runway environment environment and aerodynamic stall. Contributing to the accident work the casual attitude toward compliance with standards, inadequate hiring training and operational oversight of the flight crew . The company's lack of formal safety program. The federal aviation administration's insufficient oversight of the company's training program and flight operations. 

Thank you. Is there a motion to adopt the probable cause as proposed. I'm not aware of any amendments. The motion has been made and seconded. The probable cause has been adopted. Please read the proposed recommendation. 

Staff proposes 13 new safety recommendations to the federal aviation administration and there are nine. Require all 14 code of federal regulations operators to install flight data recording devices capable of supporting flight data program. After the action and safety recommendation is completed require all 14 code of federal regulations part 135 operators to establish a structure flight data monitoring program the reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues. Require all 14 code of federal regulations part 135 operators to establish safety management system programs. In conjunction with textron aviation the 700 and 800 series trading -- training center develop and incorporate into hawker 700 and 800 series pilot training programs a procedure that aligns with the stabilized approach criteria outlined in advisory circular 120-71a and eliminates configuration changes at low altitudes. The training centers develop and incorporate into hawker 700 and 800 series pilot training programs a definition of the term landing a short -- assured that aligns with the code of regulations. Require 14 code of federal regulations cfr part 121 operators and 14 cfr part 142 training centers to train flight crews in the performance and use of continuous descent final approach technique as their primary means for conducting non-precision approaches. Issue a safety alert for operators describing the circumstances of this accident and reminding operators to ensure that current and accurate information is entered into weight and balance software programs used in their operations. Review the safety assurance system and develop and implement procedures needed to identify 14 code of federal regulations part 135 operators that do not comply with standard operating procedures. Review the problems with the quality of the cockpit voice recorder data in this accident to determine why the problems were not detected and corrected before the accident despite the requirements in federal aviation administration order 8900.1. And determine if the procedures in advisory circular 20-186 would have ensured that the cvr problems were identified and corrected before the accident and if not revised ac 20-186 to ensure that such problems will be identified and corrected. There are two recommendations. The first work with the federal aviation administration and hawker 700 and 800 series trading centers to develop and incorporate pilot training programs in non-precision approach procedure that aligns with the stabilized approach criteria outlined in advisory circular 120-71 a and eliminates configuration changes at low altitude. Work with the federal aviation administration and hawker 700 and eight hundred series training centers to develop and incorporate into hawker 700 and 800 series pilot training programs a definition of the term landing assured that aligns with the language of 14 code of federal regulations 91.175 . Recommendations to hawker 700 and 800 series trading centers. The first work with the federal aviation administration to develop and incorporate into hawker 700 and 800 series pilot training programs a non-precision approach procedure that aligns with the stabilized approach criteria outlined in advisory circular 120-71 a and eliminates configuration changes at low altitudes. Work with the federal aviation administration to develop and incorporate pilot training programs the definition of it term landing assured that aligns with the landing of 14 coded federal regulations 91.175 c one. 

Are there any proposed amendments to the recommendations? i have a question to ask the staff. I'm just noticing that several of these are specific to hawker 700 and 800 series airplanes. About the stabilized approach. Landing assured. 11 about landing assured. Number six is generic to all types of aircraft. Assuming the issues are not unique to this type of airplane and landing assured issues are not limited to this type of airplane i want to get some background on the recommendations being limited to these airplanes. Just give me some background . I understand that's what this accident is about.

The accident investigation itself was limited to looking at the 700 and 800 programs. The cd affect -- cdfa recommendation -- 

Do you view that as inconsistent in a way? that's a pretty generic issue. Historically how have we handle that kind of situation? 

For the landing assured we only have the information from these two airplanes. 

Is there a motion to adopt the recommendations as proposed? is there a second? the motion has been made and seconded. The vote is for non-zero. Is there a motion to a adopt the report in its entirety as revised? 

Now that the board has added maintenance and operations oversight i noticed the finding we just amended was in the section of the report dealing with oversight execuflight pilot training. We can put that where it needs to be. 

We will assure language consistency throughout the report. 

I move that we adopt the report as revised. 

Is there any second to that motion? Motion has been made and seconded. All in favor of adopting the entire report as revised signal with a hand. The vote is in favor of adopt thing as revised. To any members wish to file a concurring or dissenting statement ? In closing I would like to recognize the hard work of the ntsb staff in producing this report in such a timely manner in less than a year and to thank my fellow board members for their very thoughtful participation in this process. I would like to commend our research and engineering staff because the airplane was not required to have the flight data recorder. By good fortune there was abundant radar available. The staff was able to combine this radar information to determine the accident sequence. Today we did not address recorders for accident investigation. We recommend installing flight data monitoring to evaluate and correct pilot behavior in order to prevent accidents such as the one that we considered today. Flight data monitoring can provide the fuel for continuous safety improvement. Today's recommendations will help all part 135 operators to make sure their flight operations are safe and in compliance with regulations and standard operating procedures. I will help the faa to identify operators with a systemic disregard for regulations and safety. These companies must improve their practices or close their doors. All companies have a responsibility to follow regulations and actively manage safety in all facets. Passengers expect to be flown by confident well-trained pilots were flown by companies that provide -- comply with regulations and operate safely. Today's recommendations will help to make this expectation a reality in all operations. Thank you for coming. We stand adjourned.

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