Federal investigators determined numerous mistakes by the two-person flight crew primarily caused the Nov. 10 small jet crash that killed them and their seven passengers as they attempted to land at Akron Fulton International Airport in bad weather.
National Transportation Safety Board staff questioned whether the co-pilot who was flying the jet at the time of the crash was capable of operating the craft safely. The NTSB found other contributing factors to the crash, pointing fingers at the charter jet company, ExecuFlight in Florida, as well as at lax oversight by the Federal Aviation Administration.
A “disregard for safety” extended to “organizational factors, scheduling and other practices” that predated the doomed flight, the NTSB board chairman said in opening statements Tuesday morning in Washington, D.C. The hearing was live-streamed over the web.
The NTSB said the probable cause of the Akron crash was the flight crew’s “mismanagement of the approach and multiple deviations from company standard operating procedures which placed the airplane in an unsafe situation.”
Contributing to the crash was “the casual attitude toward compliance with standards, inadequate hiring, training and operational oversight of the flight crew, and the company’s lack of formal safety program,” the NTSB said.
Also, the FAA provided insufficient oversight of the company’s training program and flight operations, the NTSB said.
“We found a flight crew, a company and FAA inspectors who fell short of their obligations in regard to safety,” NTSB Board Chairman Christopher Hart said in his opening statement. “Protections built into the system were not applied, and they should have been.”
Attempts to reach ExecuFlight for comment Tuesday were unsuccessful.
The NTSB staff listed 28 findings as part of its investigation.
Among the findings, both pilots may have been fatigued during the flight that hurt their performance, investigators said. There was no evidence of them being under the influence of drugs, alcohol or medical conditions.
There also was no evidence of structural or engine failure of the jet, the NTSB said.
Hart said that the “disregarded procedures” the NTSB found “read like pages from a basic text for preventing accidents, derived from a long history of accidents in aviation. Yet these procedures, and the accident lessons that they represent, were ignored.”
ExecuFlight also shared blame, he said.
For example, the company gave the jet pilot captain, Oscar Chavez, a “100” on what is called a crew resource management multiple choice test when Chavez actually merited a failing grade of “40,” he said. The crew resource management issues glossed over by ExecuFlight in the test “featured prominently in the accident,” Hart said.
Checklist not done
NTSB investigator Jim Silliman said the jet’s “approach briefing was unstructured, inconsistent and incomplete. And the approach checklist was not performed.”
Co-pilot Renato Marchese, who was flying the jet, put it in danger by slowing the craft, likely because flight captain Chavez expressed concerns about another aircraft in the region, he said. Company policy was to have the captain, not co-pilot, fly a jet carrying passengers.
“Although the captain recognized the situation, he never took control of the airplane and allowed the first officer to continue,” Silliman said.
The jet should have been flying at about 165 mph, or 144 knots, on its approach to Akron Fulton but instead was at 125 mph, or 109 knots, the NTSB said. The jet’s wing flaps also should have been in a different position, the safety board said.
As a result, the jet stalled and then crashed well short of the Akron Fulton runway, the investigation showed.
Besides mistakes made in flying the Hawker 127-700 jet, the two pilots also miscalculated the weight of passengers, luggage and fuel, contrary to company procedures.
Fire prevents escape
Some passengers may have been able to survive the crash impact but the subsequent rapidly spreading fire made escape unlikely, the NTSB investigation showed.
The NTSB said the jet’s captain, Chavez, had multiple opportunities to take control of the jet and fly around for a second approach to Akron Fulton. Investigators said they do not know why the captain did not do so.
The NTSB noted that Chavez had been fired from his previous job for failing to show up for what is called recurrent training, and the co-pilot, Marchese, had been fired from his previous job for “significant performance deficiencies.”
Jet operator ExecuFlight did not do a follow-up evaluation on the reasons why the two pilots were terminated from their previous employers, the NTSB said. The company missed an opportunity to determine if the co-pilot was capable of operating an airplane safely, the NTSB said.
The first officer/co-pilot Marchese likely was fatigued during the approximately 40-minute flight from Dayton to Akron from not having adequate rest from a previous trip, the NTSB said. Marchese was supposed to have 10 hours rest before flying and evidence showed he had seven hours and 45 minutes of rest, the NTSB said.
‘Sloppiness’ cited
Both pilots had insufficient rest, the investigation concluded. The board said it could not determine if insufficient rest contributed to the co-pilot’s “deficient performance.”
ExecuFlight demonstrated a casual attitude that set a poor example to pilots and for operational safety, the NTSB said. The company lacked what is called a safety management system designed to establish and reinforce a positive safety culture, the NTSB said.
“There were a litany of failures involved in this accident,” NTSB board member Robert Sumwalt said.
The ExecuFlight organization did not do proper maintenance, did not keep proper records and had other problems, he said.
“It was infested with sloppiness,” Sumwalt said.
The ExecuFlight jet, which was flying in poor weather, crashed about two miles from Akron Fulton, killing all seven passengers and the two pilots. The jet slammed into a small apartment building off Mogadore Road in Akron’s Ellet neighborhood, close to Ellet High School. No one on the ground was hurt.
The NTSB was able to piece together what happened during the flight in part from the jet’s recovered cockpit voice recorder and also from radar records from area airport towers. Flight data recorders are not required.
The flight, which originated in Florida, left Dayton the afternoon of Nov. 10 for what was supposed to be a short trip to Akron. The passengers, from a Florida real estate development firm, were on a tour to look at Midwest properties, including in Akron, their last stop.
Jim Mackinnon can be reached at 330-996-3544 or jmackinnon@thebeaconjournal.com. Follow him @JimMackinnonABJ on Twitter or www.facebook.com/JimMackinnonABJ.