AKRON, Ohio-- Almost a year has passed since a private jet crashed into an Akron apartment, killing all seven passengers and the two pilots on board.
The chartered Hawker 125, operated by Execuflight of Fort Lauderdale, Florida, crashed on approach to the Akron Fulton Airport on November 10.
In its final report announced on Tuesday, the NTSB cited a "litany of failures" placing blame on the captain, the first officer, the company they worked for and the F-A-A.
"We found a flight crew, a company and FAA inspectors who fell short of their obligations in regard to safety," said NTSB Chairman Christopher Hart.
"The flight crew did not follow company procedures, against company procedures for example the crew flew an unstabilized approach and used an unapproved flap configuration," said Hart.
The report says the First Officer was in control of the plane as it was on approach to Akron Fulton airport but had the flaps in an improper position for the approach.
"The first officer began slowing the airplane, likely due to concerns expressed by the captain about another aircraft that they were following on the approach. The first officer placed the aircraft in danger of aerodynamic stall and although the captain recognized the situation, as the pilot in command of the flight, he never took control of the airplane and allowed the first officer to continue," said Managing Director Tom Zoeller.
The NTSB says the pilot should have called off the landing but didn't.
"About fourteen seconds after the airplane descended below the MDA the captain instructed the first officer to level off as a result of the increased drag with the improper flaps at a 45 (degree) configuration and below air speed. The airplane entered a stall condition and the first officer attempted to arrest the descent about seven seconds after the captain's instructions to level off. The cockpit voice recorder recorded the first sounds of impact," said Zoeller.
The report criticizes the flight crew for its disregard of standard operating procedures, but says that may have been a result of a culture within their company, Execuflight.
"The repeated deviations from sound operational practices identified in this investigation indicate a culture of complacency and disregard for the rules," said Robert Sumwalt.
"Execuflight's casual attitude towards compliance with standards illustrates a disregard for operational safety and an attitude that likely lead its pilots to believe that strict adherence to standard operating procedures was not required," said Zoeller.
The report also criticizes Execuflight's hiring and training procedures. It says Execuflight scored one of the pilots with a 100% on a training exercise in which he actually scored a failing grade of 40.
The NTSB says the company's scheduling and monitoring of its pilot's rest may have also played a part, saying the captain's behavior in the cockpit is consistent with fatigue and that the first officer may have also been tired from less-than-required rest before a flight the day before.
"It did not provide the first officer with adequate rest for his preceding trip. The first officer was likely experiencing fatigue which may have exacerbated his performance deficiencies during the accident flight," said Zoeller.
It also criticizes the FAA for not doing its job and properly monitoring the company.
Perhaps most heartbreaking from the report is that some of the passengers may have survived the impact itself but not the quickly spreading fire that happened almost immediately.
The NTSB concluded with a dozen recommendations directed at all charter flight companies in the country, the company that builds the Hawker aircraft, and the F-A-A.
Among those recommendations is for charter companies to better train their pilots to manage the kind of approach the plane was in at the time, for charter companies to install flight data monitoring equipment on their planes so that they can detect and correct any problems pilots may be having, and for the FAA to pay closer attention to the kind of deficiencies that lead to this crash.
"These companies must either improve their practices or close their doors," said Hart.
"The customers expected a professionally managed aircraft well as, we have already laid out, they didn't get that. Instead they got a company, Execuflight, that, I'm quoting verbage from the report, had a casual attitude toward standards and compliance," said Sumwalt.