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Corporate Airlines N875JX

BAe Jetstream 32
Crew schedule information
During post-accident interviews, Corporate Airlines’ director of operations (former chief pilot)
told investigators it was difficult to maintain a pilot-staffing level sufficient to crew the company’s
scheduled flights and although the company flight schedules were legal it was a challenge to
balance what pilots wanted and what the company needed. He stated the pilots who commuted
to their duty station typically wanted as much flight time as possible per duty day so they could
complete their assigned flight hours efficiently and maximise their time off. He indicated that
pilots would be pleased if he assigned them 7 or more hrs of flight time per day with 3 duty
days per week, rather than fewer hours per day with more duty days.

Several Corporate Airlines managers and pilots commented that the long days scheduled by
the company could be tiring, especially when ceilings and visibilities were low. One Corporate
Airlines captain/check airman stated that pilots complained about scheduled flight and duty
times when their workload increased during periods of bad weather and that the lack of an
autopilot could increase crew fatigue especially when operating in adverse weather.

According to Corporate Airlines’ Director of Safety at the time of the accident, examination of
the company database of pilot-reported and other safety issues revealed no reports of fatigue.
However the FAA’s principal operations inspector (POI) for Corporate Airlines indicated that he
had frequent discussions with Corporate Airlines managers and pilots about the company’s
management of crew duty time. He stated he typically got one telephone call a month from a
Corporate Airlines pilot expressing concern about crew duty days. He stated Corporate Airlines
was short-staffed and tried to optimise its pilot scheduling to make use of the available pilots.

Flight and duty time information

Sunday 17th Oct
 Commuted from New Jersey & Ohio to STL

 3 flights, 3:03hrs flt time, 7:55hrs duty time, 15hrs off duty to rest.

Mon 18th Oct

 4 flights, 3:36hrs flight time, 6:21hrs duty time 9hrs off duty to rest

Tue 19th Oct (day of the accident)

 Hotel records show wake up calls at 04:10 and 04:30hrs

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 Duty period began (after 9hrs off duty) at BRL 05:14, departed BRL at
05:44hrs flew to STL and arrived at 06:44

 Scheduled to depart STL at 09:30 fly to UIN and return to STL but due to
poor wx these two flts were cancelled.

 Departed STL at 12:36hrs and flew to IRK and then returned to STL arriving
at 14:53

 Departed STL 15:13 flew to BRL then returned to STL at 17:45hrs

 Accident flight departed STL at 1842

 The pilots were on their 6th flight of the day and had flown 6:14hrs in
14:31hrs of duty time when the accident occurred.

During post-accident interviews, a Corporate Airlines pilot told investigators that he observed
the captain resting on a small couch when he was in the crew room at STL for about 45
minutes in the morning (around 0730 or 0800) on October 19. He said when he returned to the
crew room about 1030 or 1100, he saw the captain resting on the same couch. There were
three couches in the crew rest room a long couch, a regular size couch, and a small couch. The
pilot said the captain, who was 6’4” tall, was curled up on the small couch. The crew room was
a noisy meeting area, not ideal for sleeping. The captain and first officer left shortly after that to
have lunch with other pilots.

Telephone records indicated that the captain was not resting continuously between these
observations; on the day of the accident, numerous calls were made from and received on the
captain’s telephone between 0900 and 1230.

The captain’s fiancée stated that when they spoke that morning, the captain said he had not
slept well the night before and had awakened with a headache. He also discussed the bad
weather they were experiencing and mentioned that some of his flights for the day had been
cancelled.

Non-precision approach/missed approach guidance

Corporate Airlines’ BAE-J3201 aircraft manual states:

If the missed approach point is reached without establishing visual contact, a

missed approach must be initiated. In the event that visual contact is made with the
runway, the non-flying pilot will call, “runway in sight” and will continue to make the
appropriate altitude callouts, referenced to airport elevation. Upon hearing the
“runway in sight” call by the non-flying pilot, the flying pilot will transition to visual

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cues outside the cockpit, and upon seeing the runway/airport will state, “Going
visual, leaving minimums, flaps 35 degrees.”

Upon reaching the missed approach point, if the non-flying pilot has not stated
“runway in sight” or if transition to visual cues is not possible, or if the aircraft is not
in position for a normal landing, the flying pilot will initiate a missed approach by
stating, “missed approach.” If the non-flying pilot established visual contact with the
runway environment after the MDA was reached, that pilot would call, “approach
lights in sight, continue.” At that point Federal regulations would allow the flying
pilot to continue the descent beyond the MDA to 100 feet above the TDZE.

Pilots cannot descend beneath the MDA unless they can see the runway
environment, in which case, they are allowed to descend to 100 feet above the
TDSE (964 feet) and continue the approach until they can see the runway itself.

Corporate Airlines’ BAE-J3201 flight manual states:

Corporate Airlines’ procedures required the non-flying pilot to make a “100 feet
above minimums” callout when the airplane was 100 feet above the MDA and then
to callout “minimums” when the airplane reached the MDA during a non-precision
approach.

An immediate missed approach is mandatory if an approach becomes unstabilised

while operating in IMC. The manual stated that 900 fpm was the maximum rate of
descent for a stabilised approach between 300 feet agl and 50 feet agl.

The stabilised approach procedure allows a 1,200 fpm descent rate from 1,000 feet
agl down to 300 feet agl. Current FAA guidance states that one of the criteria for a
stabilised approach is a descent rate no greater than 1,000 fpm below 1,000 feet
agl.

Non-precision instrument approaches

FDR and radar data and the Safety Board’s airplane performance study revealed that the rate
at which the airplane descended from the FAF to (and through) the MDA was rapid, relatively
constant, and resulted in it reaching the MDA well before the MAP. This type of descent was
consistent with the more traditional non-precision approach technique that Corporate Airlines
pilots were trained to use.

The Safety Board notes that some air carriers (including United Airlines) have adopted
alternative approach techniques for non-precision instrument approaches, such as the

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“constant angle of descent” technique. The constant angle of descent technique involves
establishing and maintaining a constant descent angle at a moderate descent rate from the
FAF to the MDA, reaching the MDA very near the MAP while meeting all crossing restrictions
described on the non-precision approach plate. This constant angle of descent may be
established and maintained through the use of vertical navigation equipment or solely by
reference to published approach plate data.

As a result of the 1997 Korean Air flight 801 accident, the Safety Board issued a Safety
Recommendation A-00-14 (report published 2000), asking the FAA to do the following:

Require, within 10 years, that all non-precision approaches approved for air carrier
use incorporate a constant angle of descent with vertical guidance from on-board
navigation systems.

In a February 23, 2004, letter to the FAA, the Safety Board noted that at that time, the FAA had
incorporated a constant angle of descent in about 90 percent of the non-precision approaches
at airports that serve air carriers and that the remaining airports were scheduled to have
constant-angle-of-descent information added by September 2007.

According to Corporate Airlines, its airplanes are not equipped with vertical navigation
equipment for constant-angle-of-descent approaches

Descent rate
The initiation of the approach was consistent with company procedures; when the airplane
passed the FAF on the approach, the pilots began a 1,200 fpm rate of descent to the MDA.

The Safety Board notes that Corporate Airlines’ flight manual indicates that a 1,200 fpm
descent rate from 1,000 feet agl down to 300 feet agl is consistent with a stabilised approach.
Although this descent rate is not prohibited by the FAA, it is not consistent with the FAA’s
guidance, which indicates that one of the criteria for a stabilised approach is a descent rate no
greater than 1,000 fpm below 1,000 feet agl.

Company procedures dictate descents of no more than 900 fpm below 300 feet agl, however
the airplane was still descending at a rate of about 1,200 fpm as it descended through about
100 feet agl.

As the airplane descended through about 100 feet agl, the first officer suggested selecting
landing flaps (35°); the captain turned down the suggestion. The decision not to extend landing
flaps suggests that the captain was not completely committed to a landing, although he said he
saw the approach lights. However, the captain’s failure to stop or slow the airplane’s descent

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indicates that he was not aware of the airplane’s excessive descent rate and/or significantly
misjudged its proximity to the ground.

Sterile cockpit information

During portions of the 30-minute CVR recording, the pilots engaged in conversation that was
not directly related to the conduct of the flight. For example, about 1910:13, the captain stated
“gotta have fun” and criticised first officers he had flown with previously for being too serious.
About 1912:02, the captain transmitted a burp over the ARTCC radio frequency that would
have been heard by other pilots and air traffic controllers. An unknown voice on the radio
frequency responded to the captain’s burp, stating, “Nice tone,” and the CVR recorded the
accident pilots chuckling. About 1912:53, the captain talked about deliberately dropping a flight
manual on a passenger whose foot had intruded into the cockpit. The first officer engaged in
banter with the captain, and both pilots used informal, non-standard terminology during the
flight.

Although productive working relationships in the cockpit often involve nonessential

conversation during relatively low workload periods (which is permitted by Federal regulations),
research indicates that crews that overemphasise social team cohesion may not perform as
effectively as crews that focus on functional teamwork. Moreover, when the airplane is being
operated in critical phases of flight, including the higher workload environment below 10,000
feet msl, the “sterile cockpit” rule applies. This rule states the following, in part: No flight
crewmember may engage in, nor may any pilot in command permit, any activity during a critical
phase of flight which could distract any flight crewmember from the performance of his or her
duties or which could interfere in any way with the proper conduct of those duties. Activities
include engaging in non-essential conversations within the cockpit that are not required for the
safe operation of the aircraft.

At times, the pilots’ conversation after the airplane descended below 10,000 feet msl was not
consistent with these sterile cockpit procedures. For example, the captain and first officer
complained about passenger noise and the captain expressed a desire to make a public
announcement telling the passengers to “shut the [expletive] up.” There were many instances
where their communications were not wholly consistent with company-approved phraseology
and involved nonessential communication.

General
The pilots received thorough, accurate, and pertinent weather information for their destination
airport and were well aware that they would likely not descend beneath the clouds until at or
near the MDA. Further, they had been flying in similar weather conditions (IMC with low ceilings

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and reduced visibilities in fog and mist) all day throughout the region. Although the weather
conditions deteriorated slightly since they flew the approach earlier in the day.

CVR quotes re. the wx following receipt of the ASOS (Auto Surface Obs System)
HOT-1 ahh. We're not getting in. Three hundred sixty feet.

HOT-2 ‘expletive’. [spoken in a whispered voice]…..go all this # way…..well, let's try it.

HOT-1 yeah, we'll try it.

HOT-2 that # sucks. [sound of sigh]

HOT-1 does suck. [sound of humming] [sound of humming, yawning and tapping] I
don't want to get, go all the way out here for nothing tonight. it's gonna blow #.....
it's gonna blow the butt, blow the butt, blow the butt. what have we got here. I
thought we were gonna have it easy tonight.

HOT-2 [sound of sigh] it's three miles and mist now. [sound of sigh]

HOT-1 *. really? so it's going down the tubes.... #. , we're going into the crap. look, ooh,
it's so eerie and creepy. get a suffocating feeling when I see that. I'm drowning....
temp 'n dew point's right where you don't want it.

HOT-2 yeah, dead nuts.

CVR table
As the approach continued, neither pilot followed standard company non-precision approach
procedures. The table below lists proper procedural requirements and callouts (with the acting
pilot, if applicable), the accident pilots’ actions and responses, and pertinent remarks where
applicable. Italics text indicates deviations from procedures.

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Procedural requirements/callouts Accident pilot actions and

Pertinent remarks
(acting pilot, if applicable) responses

Regs & procedures prohibit non-

essential flight crew conversation See CVR transcript
below 10,000ft

“100 feet above minimums” callout

No such callout was recorded by CVR.
(nonflying pilot)

“Minimums” callout and look for “Thirteen twenty” – callout

1,320 feet msl was the MDA
pertinent ground references (PNF) (nonflying pilot)

As the airplane continued its Contrary to procedures and training, the

If pertinent ground references are not
descent to and through the MDA, PF was looking for external visuals
clearly visible to the nonflying pilot
the flying pilot stated, “I can see references during the approach, rather
level off at the MDA and monitor
the ground there” and “what do than levelling off and monitoring flight
cockpit flight instruments (flying pilot)
you think?” instruments.

a) Consistent with procedures, the PNF

If pertinent ground references are not
After the flying pilot said he saw was looking for pertinent ground
clearly visible to the nonflying pilot
the ground, the nonflying pilot references.
continue to look for pertinent ground
stated, “I can’t see (expletive).” b) The nonflying pilot did not challenge
references (nonflying pilot)
the flying pilot’s continued descent.

Contrary to procedures, the flying pilot

“Yeah, oh there it is, approach was the first to say he had visual cues
“Runway in sight” callout (nonflying
lights in sight” statement (flying allowing descent below MDA. Further,
pilot)
pilot) this nonstandard callout was recorded
after the plane was below the MDA.

Company procedures dictate descent The airplane’s descent rate was The first officer failed to challenge the
rates of no more than 900 fpm below consistently about 1,200 fpm until continued 1.200 fpm rate of descent
300 feet agl. immediately before striking trees. below 300 feet agl.

No such callout recorded by the CVR;

“Going visual, leaving minimums, the F/O offered but captain declined
flaps 35” callout (flying pilot) selection of flaps 35 about 4 seconds
before impact.

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Approach plate - depicting the localiser DME approach to runway 36

at IRK

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