ERA22FA004

The flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with terrain. Contributing to the accident was the captain’s poor crew resource management and failure to take over pilot flying responsibilities after the first officer repeatedly demonstrated deficiencies in flying the airplane, and the operator’s lack of safety management system and flight data monitoring program to proactively identify procedural non-compliance and unstable approaches.

The captain and first officer were assigned a two-leg overnight on-demand cargo flight. The flight crew were accustomed to flying night cargo flights, had regularly flown together, and were experienced pilots. The first leg of the trip was uneventful and was flown by the captain; however, their trip was delayed 2 hours and 20 minutes at the intermediate stop due to a delay in the freight arriving. The flight subsequently departed with the first officer as the pilot flying. While enroute, about forty minutes from the destination, the flight crew asked the air traffic controller about the NOTAMs for the instrument landing system (ILS) instrument approach procedure at the destination. The controller informed the flight crew of two NOTAMs: the first pertained to the ILS glidepath being unserviceable and the second applied to the localizer being unserviceable. When the controller read the first NOTAM, he stated he did not know what “GP” meant, which was the abbreviation for the glideslope/glidepath on the approach. The controller also informed the flight crew that the localizer NOTAM was not in effect until later in the morning after their expected arrival, which was consistent with the published NOTAM. The flight crew subsequently requested the ILS approach and when the flight was about 15 miles from the final approach fix, the controller cleared the flight for the ILS or localizer approach, to which the captain read back that they were cleared for the ILS approach. As the flight neared the final approach fix, the captain reported that they had the airport in sight; he cancelled the instrument flight rules flight plan, and the flight continued flying towards the runway. The airplane crossed the final approach fix off course, high, and fast. The cockpit voice recorder (CVR) transcript revealed that the captain repeatedly instructed the first officer to correct for the approach path deviations. Furthermore, the majority of the approach was conducted with a flight-idle power setting and no standard altitude callouts were made during the final approach. Instead of performing a go-around and acknowledging the unstable approach conditions, the captain instructed the first officer to use the air brakes on final approach to reduce the altitude and airspeed. Shortly after this comment was made, the captain announced that they were low on the approach and a few seconds later the captain announced that trees were observed in their flight path. The CVR captured sounds consistent with power increasing; however, the audible stall warning tone was also heard. Subsequently, the airplane continued its descent and impacted terrain about .70 nautical mile from the runway. Airport surveillance video captured the final 2 minutes of flight. Although low clouds and visibility were reported in the area of the airport, it is unlikely that the airplane entered instrument meteorological conditions in the flight’s final 2 minutes given that the airplane’s landing light was continuously in view until the airplane’s impact with trees and terrain. Furthermore, the video revealed that about the time the air brake comment was made by the captain, the airplane’s descent rate was observed to increase. Examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures with the airplane or its engines. The air brakes and their actuators were found in an extended position, the landing gear were down, and the flaps were stated by the captain to be set to full. The airplane flight manual (AFM) prohibited the use of air brakes during the approach unless anti-ice was used; however, there was no indication that anti-ice was used. It is likely that after the captain instructed the first officer to use the air brakes, the flight entered a descent that could not be recovered from, despite the rapid increase in power in the final moments of the flight. The flight profile of idle power, air brakes deployed, landing gear down, and full flaps was not a configuration that the airplane manufacturer possessed data for given that it was not an AFM approved approach configuration. The captain advised the first officer to fly the ILS approach and to follow the glideslope, despite the glideslope being out of service per the NOTAM. It was not possible to determine whether the high and low comments from the flight crew were in reference to precision approach path indicator lights, cockpit instrumentation, or a visual glidepath assessment based upon the crew’s perception of the lighted but dark night runway environment. The glideslope portion of the ILS was not broadcasting a signal due to the equipment being removed for maintenance. The investigation was unable to determine what the glideslope indications displayed in the cockpit were due to impact-related damage to the instrumentation. The approach was being conducted during dark night conditions, which likely further exacerbated the flight crew’s inability to establish a proper glide path and see the approaching trees and terrain. The controller did not state that the glideslope was out of service when he cleared the airplane for the ILS localizer approach procedure, nor was there a requirement to do so when an ILS or localizer approach was to be flown. Furthermore, when the airplane was near the final approach fix, the captain reported that they had the airport in sight, and he cancelled the instrument flight rules flight plan. The decision by the flight crew to continue straight in to land, rather than flying the procedure turn, contributed to the airplane being high for the majority of the final approach. The CVR revealed that throughout the enroute descent and approach, the captain repeatedly instructed the first officer on how to fly the airplane, reprimanding and yelling at him about basic airmanship tasks such as heading and altitude control. The captain also took control of the airplane multiple times before the final approach. The captain had ample indications that the first officer was not performing adequately to continue the flight as the pilot flying. The captain could have demonstrated leadership and positive crew resource management by relieving the first officer of flying duties well before the final approach commenced, given the challenging nature of the dark night approach that was ahead. The operator reported the first officer had not received an upgrade to captain, even after multiple years of experience on the accident airplane, due to his lack of aeronautical decision making and airmanship necessary to become a captain. This assessment was consistent with his performance during the accident flight. Furthermore, the captain’s training record showed multiple deficiencies during training. Had the operator had a flight data monitoring program (FDM) and safety management system (SMS), they could have had additional methods of identifying and monitoring the poor performing flight crew and made proactive decisions, rather than waiting for an accident to occur to discover the flight crew’s procedural non-compliance. The National Transportation Safety Board has standing recommendations to Part 135 operators to implement SMS and FDM, and for the Federal Aviation Administration to require SMS and FDM in Part 135 operations. Both pilots had cardiovascular disease that placed them at increased risk of a sudden impairing or incapacitating medical event such as heart attack or abnormal heartbeat; however, based upon the totality of the investigation’s findings, it is unlikely that the captain’s or first officer’s cardiovascular disease contributed to the accident. Furthermore, the toxicology reports for the flight crew revealed no conditions or findings that would have contributed to the accident.

The Georgia Bureau of Investigation, Division of Forensic Sciences, performed the captain’s autopsy. According to the autopsy report, the captain’s cause of death was generalized blunt force trauma, and his manner of death was accident. His heart was enlarged, weighing 600 grams (the upper limit of normal is roughly 510 grams for a male of the captain’s body weight). There was moderate-to-severe atherosclerotic disease of his coronary arteries. Visual examination of his heart was otherwise unremarkable for natural disease. There was focally severe atherosclerosis of his aorta. Examination of his brain was limited due to the severity of injury. The autopsy did not identify any other significant natural disease. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the captain. No tested-for substances were detected. The Georgia Bureau of Investigation, Division of Forensic Sciences, performed the first officer’s autopsy. According to the autopsy report, his cause of death was generalized blunt force trauma, and his manner of death was accident. He had severe atherosclerotic disease of his coronary arteries. Visual examination of his heart was otherwise unremarkable for natural disease. He had focally severe atherosclerosis of his aorta. The autopsy did not identify any other significant natural disease. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the first officer. Losartan, rosuvastatin, and acetaminophen were detected in cardiac blood and urine. The glucose levels in vitreous and urine were measured to be 13 mg/dL and 5 mg/dL, respectively. Approach Speed The airplane’s landing reference speed, Vref, for flaps 40° (which was indicated in the CVR transcript), 20,000 lbs, and no airbrakes was 113 kts. This speed was consistent with what was found set with the speed bugs on both the pilot and co-pilot airspeed indicators (115, 110 knots, respectively). Air Brakes According to the DA20 maintenance manual and operating manual, the air brakes are electro-hydraulic devices on both wings situated on the upper surface that permits aerodynamic braking of the airplane in flight. The maximum deflection is 70° and they are held in place by hydraulic pressure. The airbrakes are deployed through the use of a handle located on the center console of the cockpit closer to the left seat pilot. The air brakes operate in a deployed or stowed configuration. The time to extend the air brakes is 2 to 3 seconds and retraction is 3 to 4 seconds. There were two annunciator lights associated with the deployment of the airbrakes. The DA20 AFM stated in part that the airbrakes were to be checked IN during the approach. The manual further states that, “In approach with flaps extended, the airbrakes must be retracted. If the approach is made with the anti-ice on, the airbrakes may be extended down to 500 ft above the ground.” Furthermore, the approach speed must be increased by 10 kts as long as the air brakes are out. Based upon a review of the CVR transcript, an engine sound spectrum study, and review of meteorological information, there was no evidence that the anti-ice system was on during the approach. Aerodynamic Stall Speed and Systems Information Based upon an expected landing weight of 20,280 lbs and the airplane’s equipped instrumentation, the aerodynamic stall speed was likely about 91 KIAS (Flaps 40°) and 95 KIAS (Flaps 25°). The AFM airspeed limitations stated: CAUTION: DO NOT INTENTIONALLY FLY THE AIRPLANE SLOWER THAN INITIAL STALL WARNING ONSET According to Dassault Aviation representatives, there was no data that existed as to what flight characteristics the airplane would demonstrate in an idle power, full landing flaps, landing gear down, and air brakes deployed configuration. The airplane was equipped with a multi-faceted stall warning system. According to the operations manual, the stall warning system was designed to inform the pilot of a forthcoming stall by sounding an aural warning. When the airplane is approaching stalling conditions a modulated medium pitch will sound 2/3 seconds on, 1/3 seconds off. Operator Information The operator, Pak West Airlines, dba Sierra West Airlines (SWA), held a Title 14 CFR Part 135 air operator certificate with the FAA. According to SWA records, the accident flight crew flew together routinely and commonly performed overnight flights. The flight crew schedules, and duty day were consistent with Part 135 regulations. The SWA DA20 standard operating procedures stated that during visual approaches the PNF (pilot not flying) was to announce 1,000 ft, 500 ft, 100 ft, and 50 ft agl altitude callouts. The CVR transcript revealed that none of these altitude callouts were made by the captain, who was the pilot not flying. The SWA General Operations Manual (GOM) defined “stabilizing approach concept” as the procedure by which the crew maintains a stable speed, configuration, descent rate, vertical flight path, and engines spooled. The GOM further outlined that both pilots were responsible for ensuring the approach was stabilized before continuing below minimum altitudes that varied dependent upon the type of approach being flown. The minimum altitude for visual approaches was 500 ft agl. The GOM further provided a warning that that the flight crew was responsible for taking “immediate action” of a go-around or missed approach if “stabilized conditions” are not met. The GOM stated that it was critical to flight safety that either pilot had the ability to call for a go-around if they believe an unsafe condition exists. The go-around action was required to be associated with immediate action of executing a missed approach, without question, because of the immediacy of the situation. Captain According to the operator’s training and employment records, in September 2019 the captain satisfactorily completed indoctrination training and ground training and was subsequently assigned to the DA20 as a pilot in command. The captain completed multiple airman competency/proficiency checks from 2019 through 2021. Each check was ultimately completed satisfactorily; however, multiple line checks required retraining and testing due to unsatisfactory performance of required task items. Some example areas that were required to be retrained and tested were circling approaches and steep turns. According to the captain’s resumé and records from his former employer Ameristar Jetcharter Inc. (Ameristar), he was employed by the operator as a pilot from June 2017 through August 2019. On December 22, 2017, an airman competency/proficiency check (14 CFR 135.293 and 135.297 checks) in a DA20 simulator was marked as disapproved. The remarks from the check airman stated in part that during instrument procedures the captain was “cleared for right turn by ATC, mis-set hdg bug resulting in left turn. Distraction resulted in loss of airspeed to full stall condition.” A few days later, the pilot satisfactorily completed the check. He served as SIC through mid-January 2018 and was subsequently upgraded to PIC. First Officer According to operator training and employment records, on August 20, 2009, the first officer was hired and assigned to the DA20 as an SIC after satisfactorily completing indoctrination training and ground and flight training. The pilot left the operator for 5 years, returned in 2019, and was reassigned again as an SIC DA20 flight crewmember. On December 30, 2020, an airman competency/proficiency check (14 CFR 135.293) was completed satisfactorily with remarks that stated, “SIC Only.” The operator reported that the first officer was designated as a SIC only due to pilot performance and a lack of aeronautical decision making and airmanship necessary to become a PIC/captain. On October 5, 2021, at 0544 eastern daylight time, a Dassault Falcon 20C airplane, N283SA, was destroyed when