ERA24FA136

The PIC’s continuation of an unstabilized approach in gusting wind conditions and his failure to monitor the airplane’s altitude during the approach, which led to a descent into terrain short of the runway. Contributing was the flight crew’s failure to set the appropriate altimeter setting and failure to properly configure the avionics for the ILS approach.

Following an uneventful flight, the flight crew was descending the twin-engine business jet for landing at the destination airport, which was equipped with a 5,600-ft-long runway and located on a mountain ridge. Cockpit voice recorder (CVR) audio indicated that the pilot-in-command (PIC) was the pilot flying and the second-in-command (SIC) was the pilot monitoring. Air traffic control provided the crew with the local altimeter setting as they began their descent from cruise altitude about 24 minutes before the accident. About 12 minutes later, the crew informed the controller that they had obtained the weather information at the destination. Shortly thereafter, the controller cleared the crew direct to an intermediate fix on the intended instrument landing system (ILS) approach, instructing them to cross the fix at or above 6,100 ft mean sea level (msl). The crew acknowledged and began turning toward the final approach course. About two minutes later, the controller queried the crew about their altitude, stating that he observed the airplane at 5,900 ft msl. The crew responded that they were at the assigned altitude and continued the approach. Given that the CVR did not record the crew performing any crosscheck or verification of the altimeter settings as they descended, nor did it capture the crew conducting an approach briefing, the controller’s observation that the airplane 200 ft lower than its assigned altitude suggests that the crew did not reset the airplane’s altimeter setting during the descent. As the crew descended toward the final approach fix, the SIC asked the PIC if he would like the airplane’s flight guidance system (FGS) set to vertical speed (VS) mode, which the PIC confirmed. In this mode, the airplane’s autopilot would maintain a specified descent rate set by the crew, and would continue to descend to the set altitude at the specified rate of descent regardless of the airplane’s position on the glideslope. As the airplane neared the final approach course, the SIC stated that FLOC was captured on both sides. This likely referenced a flight management system (FMS)-generated final approach course based on the waypoints that had been programmed into the system, rather than the localizer signal broadcast by the ILS. If the ILS frequency had been tuned and selected as the navigation source, the display should have indicated LOC, not FLOC. About 7 miles from the runway threshold (about 3 minutes before the accident), the crew began to configure the airplane for landing. The PIC stated that he had the airport in sight, and shortly thereafter, the SIC confirmed that he also had the airport in sight. Upon crossing the final approach fix, the PIC began a descent and the SIC extended the landing gear. There was no mention of a change in autopilot mode, and it is likely that this descent was also performed in VS mode. The PIC called for the before landing checklist, which the SIC completed, concluding the checklist by reporting to the PIC that the airplane was below glideslope. About 1.5 nautical miles (nm) from the runway, the SIC reported full deflection below glideslope. Shortly thereafter, the SIC announced that the airplane was 15 knots above reference speed. About 30 seconds before the accident, the PIC turned the autopilot off. Shortly after the automated Enhanced Ground Proximity Warning System (EGPWS) 1,000-ft annunciation, the SIC suggested a go-around; the PIC did not respond. The SIC again called for a go-around just before the EGPWS 500-ft annunciation; again, the PIC did not respond. About 3 seconds later, the airplane impacted rising terrain about 300 ft before the runway threshold. Based on the SIC’s statement that FLOC was displayed, it is likely that the flight crew did not arm the approach on either the FMS or FGS, and as a result, the system did not automatically tune the ILS frequency or capture the glideslope. Alternatively, the flight crew could have manually tuned and verified the ILS frequency on the ILS receiver. The flight crew was likely seeing advisory lateral and vertical guidance on the flight instruments based on the waypoints and altitudes input into the FMS; however, to obtain glideslope vertical guidance, the ILS frequency would need to be tuned and selected, and approach mode would need to be armed. Additionally, given the crew’s failure to properly set the altimeter, the SIC’s programming of the autopilot in VS mode to a final altitude of 4,100 ft would have resulted in the airplane descending to a true altitude between 3,800 ft and 3,900 ft before the autopilot would attempt to maintain altitude. The airport was located at an elevation about 3,792 ft msl. The airplane’s EGPWS was capable of producing an aural “Glideslope” alert for a deviation in excess of 1.3 dots fly up (as depicted by a glideslope needle deflection of 1.3 dots above the cockpit glideslope indicator’s centerline) if the ILS was tuned and providing deviation information to the EGPWS. The accident airplane deviated beyond 1.3 dots fly up multiple times with no glideslope aural alert heard on the CVR. The EGPWS was also capable of producing radio altitude callouts for non-precision approaches and a review of the CVR found three of these callouts were heard, at 2,500 ft, 1,000 ft, and 500 ft. Based on the lack of a “Glideslope” aural alert, it is likely that the ILS was not tuned. Therefore, the flight instruments would not have received or displayed lateral localizer or vertical glideslope deviation information and the EGPWS would not have the required inputs to provide the aural “Glideslope” alert. A review of the data recovered from the airplane’s EGPWS unit revealed that the software was not updated in accordance with an FAA special airworthiness information bulletin (SAIB) applicable to the accident airplane, nor had the EGPWS been wired directly into the airplane’s GPS as specified in the SAIB. Had the operator completed these actions, it is likely that, based on the accident flight path, the flight crew would have received an EGPWS “too low terrain” aural alert about one mile from the end of the runway, which may have prompted the PIC to take corrective action. The PIC obtained his type rating in the accident airplane make and model about two months before the accident. A review of his training records found that multiple instructors had listed flight management system (FMS) use as one of the pilot’s weaknesses. About six months before the accident, the PIC had been dismissed from another operator due to his lack of adherence to SOPs, poor CRM, poor checklist usage, inability to manage the FMS, and poor aircraft control. The accident airplane operator’s stabilized approach policy required that a missed approach or go-around be initiated immediately upon an approach becoming unstable below 1,000 ft above airport elevation when in instrument meteorological conditions and below 500 ft when in visual meteorological conditions. During the approach, the PIC exceeded multiple criteria that should have resulted in a missed approach or go-around, including reference speed, glideslope deviation, and descent rate parameters. Snow showers were reported in the area around the time of the accident; however, the crew reported the airport in sight about two minutes before the accident and the CVR recording did not subsequently indicate that they lost sight of the runway. Therefore, it is likely that they remained in visual contact with the airport throughout the final portion of the approach. The wind conditions at the time of the accident were conducive to updrafts and downdrafts. It is likely that the crew encountered these conditions during the accident approach, which may have contributed to the airplane’s deviation from stabilized approach criteria and its subsequent impact with terrain; however, the PIC had ample time to complete a go-around or missed approach if he had initiated

Pilot in Command (PIC) The PIC moved to the United States in 2014 from Venezuela. He held Venezuelan pilot certificates that were converted to FAA certificates after he relocated. The PIC was the officially designated Part 135 Chief Pilot at SkyJet Elite. According to the former Director of Operations (DO) of SkyJet, who worked for the operator for about four years and ceased employment with them in November 2023, the PIC was hired as the Chief Pilot “in name only” and was a “place holder.” The former DO explained that the PIC/Chief Pilot had little to no involvement in SkyJet during his tenure as DO at the operator. The PIC began new hire training in September 2022. The former DO and current DO of SkyJet reported that the PIC was supposed to fly Piper PA31 Navajo airplanes on the SkyJet Part 135 certificate. But from the fall of 2022 through the entirety of 2023, the pilot never completed a Part 135 checkride. An oral exam (135.293a) was completed with the South Florida FAA Flight Standards District Office (FSDO) twice; however, the practical examination was never attempted due to maintenance issues with the PA31 airplanes. According to both SkyJet DOs, the pilot worked at other Part 135 operators while being named as the Chief Pilot at SkyJet, including Aztec Airways and REVA, a Part 135 Learjet air ambulance operator. According to REVA, the PIC was hired in May of 2023 as a PIC candidate for the Learjet 31. REVA reported that he struggled tremendously at FlightSafety PIC ground and simulator training and that he needed extra training time. He initially failed his Part 135 PIC checkrides before passing after additional training. Although the PIC passed the Flight Safety training, REVA downgraded his assignment to SIC. Three standards captains at REVA were interviewed, and all provided similar accounts of the PIC’s performance during his initial operating experience after completing his training at FlightSafety. They stated that the PIC demonstrated a lack of adherence to standard operating procedures (SOPs), poor crew resource management (CRM), poor checklist usage, required constant reminders, could not manage the FMS, and had poor aircraft control. One captain stated that they could not believe he passed FlightSafety training and was sent to the line. In September 2023, the PIC was dismissed from REVA. The current DO for the accident operator stated that in December 2023, when a decision was made to allow the PIC to attend PIC training for the accident airplane make and model, his employment file did not include a background check or fingerprints. The SkyJet DO said that he did not run a Pilot Records Improvement Act (PRIA) or Pilot Records Database (PRD) check in December 2023, because the PIC was not a new hire. The PIC underwent ground and simulator training on the accident airplane make and model in January 2024. He completed 11 simulator training sessions from January 12, 2024, through January 27, 2024, before taking his checkride on January 28, 2024. A review of the flight instructor’s comments showed FMS as a weakness in 8 of the 11 simulator sessions, including the session before the checkride. There were also multiple comments stating that the PIC had set the wrong minimums during instrument approach procedures. During the simulator session before the checkride, the PIC was paired with a different instructor than his primary instructor for the purpose of a line-oriented simulator training session. The instructor was interviewed and reported that after the session he felt the PIC was not ready for the checkride and needed more training. The recommendation the instructor wrote on the grade sheet stated “Needs a lot of help with the FMS. Client needs much more training time to be a safe and effective PIC.” The pilot passed his checkride on January 28, 2024, and was issued a PIC type rating on the accident airplane make and model (G-100, IA-1125). Second in Command (SIC) A review of FAA airman records showed the SIC had received a notice of disapproval during his first attempt to obtain an instrument rating on September 4, 2020. The comments from this disapproval indicated that he did not properly tune and identify the ILS frequency, misidentified approach minimums and leveled off early, and was high on the approach. The SIC received a temporary airman certificate for his instrument rating on September 17, 2020. On July 23, 2021, the SIC received another notice of disapproval during the practical test for his commercial pilot certificate, indicating weaknesses in aircraft systems knowledge and emergency procedures. He received a temporary airman certificate for his commercial pilot certificate on July 25, 2021. The SIC was hired by the operator in March of 2023 and received a SIC type rating for the IA-1125 and G-100 in November of 2023. The SIC’s instructor at FlightSafety for his type rating reported that the SIC “improved very quickly,” and “was a very good student.” As of the date of the accident, the SIC had accumulated a total of 136 hours in the accident airplane make and model, all of which was SIC time. SkyJet Elite was a Part 135 operator based in Fort Lauderdale, Florida. The flight was dispatched as a Part 91 non-revenue flight with SkyJet Elite’s CEO onboard, with a SkyJet PIC and SIC. Also onboard were the CEO’s wife and child. The flight crew were due to continue Part 91, repositioning to Teterboro, New Jersey, after the passenger drop off at Hot Springs. On March 12, the flight crew were scheduled for Part 135 flying in the accident airplane. A dry lease agreement for the accident airplane stated that operational control for all flights would be the responsibility of SkyJet Elite. The operator had a total of four Astra jets on the certificate, a Citation, and a Learjet. The PIC and SIC were qualified and current to operate the airplane for Part 91 and Part 135 operations. The airplane was equipped with a Universal Avionics UNS-1Lw Flight Management System (FMS). Neither the FMS manufacturer’s operator’s manual nor the SkyJet Elite’s training manual provided a description of FLOC. A production test pilot for the airframe manufacturer, who was familiar with the FMS system, described FLOC as: In this mode, the system is in position for a transition from long range navigation (FMS) to short range navigation (LOC) (commonly referred to as a “NAV-to-NAV” transfer), but it is tracking the course laterally using FMS. It is incapable of actually tracking the ground based LOC in this mode, but a representation (“ghost” needles) of the localizer course and glideslope is displayed on the PFD and HSI for crew awareness as indicated by the FLOC and symbology on the displays. It will not capture the glideslope, it is still in a baro-referenced altitude mode. In order to couple to the LOC and GS to fly the ILS, the crew must select approach mode in the flight guidance system by selecting the APPR button on the Mode Selector Panel. Once APPR is selected, the FMS will switch flight guidance to LOC when within parameters. FLOC will change to LOC on the displays and there will be a color change in the CDI needles. Once the LOC is captured, the GS will capture when it is within parameters. Once this is accomplished, the airplane will fly the ILS like any conventional non-FMS aircraft, but the waypoints in the approach will sequence so that a transition back to FMS can occur in case of a go-around or missed approach. The Virginia Office of the Chief Medical Examiner Western District determined the cause of death for both pilots as blunt injuries to the head, torso, and extremities and the manner of death for both pilots as accident. The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the PIC. Ethanol, drugs of abuse, and carboxyhemoglobin were not detected. Losartan was detected in cavity blood and liver tissue. Losartan (Cozaar