NTSB Factual Report

HISTORY OF FLIGHT

On September 20, 2003, at 1854 central daylight time, a Hawker Siddeley HS-125-700A, N45BP, operated by Starflite Management Group, Inc., of Houston, Texas, was destroyed when it impacted terrain approximately 15 miles northwest of Southeast Texas Regional Airport (BPT), Beaumont, Texas. The airline transport certificated flight instructor, and the airline transport pilot and commercial pilot who were receiving instruction (hereinafter referred to as the instructor-pilot, first pilot, and second pilot, respectively) were fatally injured. Visual meteorological conditions prevailed. An IFR (instrument flight rules) flight plan had been filed for the instructional flight being conducted under Title 14 CFR (Code of Federal Regulations) Part 91. The flight originated at Houston-Hobby Airport (HOU), Houston, Texas, at 1759.

According to the Federal Aviation Administration (FAA), the instructor-pilot was preparing the first and second pilots for their FAA Part 135 competency and proficiency checks scheduled to be conducted in the accident airplane the following week. Operator proving tests were to follow shortly thereafter. The operator, Starflite Aviation, had five other airplanes on its air carrier certificate: a Beech 200 King Air, an IA-1121 Commodore Jet, two IA-1124 Westwinds, and a Lockheed L-1329 JetStar.

According to FAA documents, the first pilot obtained a CSC (Computer Science Corporation) DUATS (Direct User Access Terminal Service) weather briefing and filed an IFR flight plan, indicating the airplane would fly to Beaumont in 23 minutes at 250 KTAS (knots true airspeed) and at 5,000 feet. The instructor-pilot was listed as the pilot-in-command. An IFR clearance to Beaumont was issued at 1748, and taxi clearance to runway 22 came at 1749. After the 1759 takeoff, the crew contacted Houston Departure Control at 1801, and was handed off to Beaumont Approach Control at 1810. At 1815, the flight was cleared into a practice area, the boundaries being between the 270-degree and 360 degree radials and within 20 DME (Distance Measuring Equipment) miles of the Beaumont VORTAC (Very high frequency Omnidirectional Radio range TACtical Air Navigation). The airplane was to remain between 5,000 and 7,000 feet msl. At 1828, Beaumont Approach Control instructed the crew to turn eastbound because they was approaching the fringes of its practice area and entering Houston airspace. The crew acknowledged and said that they were turning around. That was the last radio contact with the airplane.

The closed-loop cockpit voice recorder, that records ambient cockpit sounds for the past 30 minutes, started at 1822:50 and ended at 1854:27. Only the last 13 minutes of the recording, beginning at 1841:14 and ending at 1854:27, were transcribed. Prior to the start of the transcript, several steep turns and stalls had been performed. The second pilot was complimented on his performance. He remarked that he had never flown a jet before and would have to get use to its feel. The instructor-pilot then asked the first pilot to perform a stall in the approach configuration. The first pilot asked the instructor-pilot if he had "ever done stalls in the airplane?" The instructor-pilot replied, "It's been awhile." The first pilot remarked, "This is the first time I've probably done stalls in a jet. Nah, I take that back, I've done them in a (Lear)." The instructor-pilot said he had stalled "the JetStar on a [FAR] one thirty five ride."

At 1848:18, the first pilot asked for approach flaps (15 degrees) and for the landing gear to be lowered. The second pilot complied. The stall was performed and the recovery was accomplished. At 1849:57, the second pilot announced, "Five thousand feet, gear's up and locked. Vee two plus twenty, your flaps [are] up."

At 1850:22, the instructor-pilot briefed the pilots on the next maneuver, an approach-to-landing stall: "Okay, accelerate back to two hundred knots, five thousand feet. Find the ref[erence] speed. Do the checklist for the ref speed for our weight. We're at uh fourteen and seven is twenty one. Approach to landing stall is next. What did I say, twenty one? One twenty two for the ref. Your power is gonna be back at idle, you know. What else? Flaps. You know, approach flaps, gear. You don't wanna get flaps in there * late. No, no more trimming past, I think its one fifty or one sixty. Recover. Just like a go-around maneuver. Power, positive rate, flaps ten, okay, positive rate. Gear up. Ref plus twenty. Flaps up." The second pilot questioned the configuration: "So this one the flaps don't go all the way to forty-five, they just go to twenty-five?" The instructor-pilot said, "No, full flaps." A discussion followed as to whether the stall should be performed in a turn or straight ahead. It was decided that the stall would be done straight ahead.

At 1852:58, the first pilot asked for approach flaps and then for the landing gear to be lowered. The second pilot then reported, "Flaps twenty-five, set." The first pilot said, "Flaps," and the second pilot replied, "Flaps," and there was the sound of a click. The instructor-pilot reminded them, "*** power," and there followed the sound of decreasing power. According to the digital electronic engine control (DEEC) data, power decreased to 37 percent N1. At 1953:57, the stick shaker sounded. Radar-computed ground speed was 192 knots and decreasing rapidly. Altitude was 4,900 feet msl. DEEC data depicted a commanded increase to takeoff power and the instructor-pilot said, "Aww, don't do that now." DEEC data then showed a commanded power reduction to between 30 and 40 percent N1. At 1854:03, the first pilot said, "Gimme flaps." At 1854:08, the second pilot asked, "What do you want me to do?" Ground speed was between 112 and 113 knots. At 1854:10, the first pilot said, "Recover." There was the sound of increasing background noise, and at 1854:17, the second pilot said, "Power up, power up, power. Do something, man." The instructor-pilot said, "Power up." DEEC data did not record any increase in power, even though both engines were operating and controllable by pilot command. The CVR recording ended at 1854:27. Shortly thereafter, during the 1854 time frame, Beaumont Approach Control gave the flight a new altimeter setting. There was no acknowledgement. At 1855, the approach controller advised that he was not receiving the airplane's transponder signal. There was no reply. Repetitive calls were made at 1855, 1856, and 1908. There was no response to either call.

Twenty-five witnesses were either interviewed by telephone or in person. The consensus was that the airplane was flying at a low altitude and doing "erratic maneuvers." One witness said that when airplane emerged from the overcast, it "seemed to stop in midair," then it pitched nose down and disappeared behind the tree line. Several witnesses said the airplane was spinning --- some described it as a flat spin --- before it struck the marshy ground. One witness said the airplane fell "like a falling leaf."

The accident occurred during the hours of daylight at a location of 030 degrees, 08.44 minutes north latitude, and 094 degrees, 13.19 minutes west longitude, and at an elevation of 12 feet msl.

CREW INFORMATION

According to Title 14 CFR Part 1.1, the "pilot in command" is the person who: "(1) has final authority and responsibility for the operation and safety of the flight, (2) has been designated as pilot in command before or during the flight, and (3) holds the appropriate category, class, and type rating, if appropriate, for the conduct of the flight." Based on this definition, the pilot-in-command was the instructor-pilot, who, according to the CVR transcript, was seated in the jump seat. The instructor-pilot was also listed on the filed flight plan as being the pilot-in-command.

The instructor-pilot, age 36, held an airline transport pilot certificate, dated November 19, 2002, with an airplane multiengine land rating, type ratings in the Hawker Siddeley HS-125, Dassault DA-2000, and Lockheed L-1329, and commercial privileges in airplanes single-engine land. He also held a flight instructor certificate, dated January 13, 2003, with airplane single/multiengine and instrument ratings, and a ground instructor certificate, dated May 20, 1988, with a basic rating. His first class airman medical certificate, dated July 18, 2003, contained no restrictions or limitations. He was hired by Starflite in June 2003, and completed company training in July 2003. His flight training record, dated July 22, 2003, contained the following notations: "Flight 1, 2. Good control - smooth - knows flows. Flight 3. Check ride ready. Flight 4. Retrain for check ride failure." According to his resume and personnel records, he had logged the following flight time (in hours):

Total time: 5,230

Pilot-in-command: 3,521

Second-in-command: 1,455

Turbine: 3,231

Pilot-in-command, turbine: 1,776

Multiengine: 3,290

Instrument: 367

The first pilot, age 42, held an airline transport pilot certificate, dated March 25, 2003, with an airplane multiengine land rating, type ratings in the Beech 300 and Hawker Siddeley HS-125, and commercial privileges in airplanes single-engine land. He also held a flight instructor certificate, dated February 28, 2003, with airplane single/multiengine and instrument ratings. His first class airman medical certificate, dated June 30, 2003, contained no restrictions or limitations. According to his application for this medical certification, he indicated he had logged 3,800 total flight hours, of which 350 hours were accrued in the previous 6 months. Starflite hired him in August 2003. According to his resume and personnel records, he had logged the following flight time (in hours):

Total time: 3,817

Pilot-in-command: 2,684

Turbine: 1,575

Pilot-in-command, turbine: 617

Turbojet: 855

Pilot-in-command, turbojet: 80

Airplane, single-engine: 1,620

Airplane, multiengine: 2,198

Second-in-command: 873

Night: 304

Instrument: 493

Cross-country: 2,730

Instructor: 665

The second pilot, age 27, held a commercial pilot certificate, dated August 19, 2000, with airplane single/multiengine land and instrument ratings. He also held a flight instructor certificate (gold seal), dated April 19, 2002, with airplane single/multiengine and instrument ratings, and a ground instructor certificate, dated January 7, 2002, with an instrument rating. His first class airman medical certificate, dated March 24, 2003, contained no restrictions or limitations. According to his application for this medical certification, he indicated he had logged 2,000 total flight hours, of which 600 hours were accrued in the previous 6 months. Starflite hired him on September 1, 2003. Officials said the accident flight occurred on his first day of training. According to his resume and personnel records, he had logged the following flight time (in hours):

Total time: 2,400

Pilot-in-command: 2,200

Airplane, single-engine: 1,100

Airplane, multiengine: 1,300

Night: 1,000

Instrument: 250

Cross-country: 1,600

AIRCRAFT INFORMATION

Hawker Siddeley manufactured N45BP (s/n NA0219, formerly N219TS), a model HS-125-700A, in 1978. It was equipped with two Garrett TFE731-3--1RH turbofan engines (s/n P-08159, left; P-80160, right), each rated at 3,700 pounds of thrust. Starflite documents indicated the program used to maintain N45BP was outlined in FAR 91.409(f)(3).

According to the maintenance records, the engines were given a "Garrett pre-purchase evaluation" on June 3, 2003, and "a list of discrepancies [were] provided to the customer." Total airframe time was 9,690.4 hours. The airplane was then placed under "Raytheon's Flexible Maintenance Schedule [FAR 91.409(f)(3)]." The airplane was last inspected in August 2003 (day of the month not given).

According to the Daily Aircraft and Engine Log, N45BP flew the day before the accident. At the end of the day, the airframe had accrued 9,780.1 hours total time and 7,098 landings. The left and right engines had accrued 9,359.9 and 9,489.9 hours, and 7,053 and 6,734 cycles, respectively, since new.

METEOROLOGICAL INFORMATION

The following METAR (routine aviation meteorological report) observations were recorded at Beaumont Airport at 1753 and 1853, respectively:

Wind, 070 degrees at 9 knots; visibility, 7 statute miles; sky condition, clear below 12,000 feet msl; temperature, 27 degrees C.; dew point, 21 degrees C.; altimeter setting, 29.97.

Wind, 090 degrees at 7 knots; visibility, 8 statute miles; sky condition, clear below 12,000 feet msl; temperature, 26 degrees C.; dew point, 21 degrees C.; altimeter setting, 29.98.

AIDS TO NAVIGATION

There were no reported difficulties with aids to navigation.

COMMUNICATIONS

There were no reported communications difficulties.

FLIGHT RECORDERS

The airplane was equipped with a Fairchild A-100a cockpit voice recorder (CVR). It was recovered and sent to NTSB's vehicle recorder laboratory where, on October 9, 2003, the CVR Group convened to audition the tape. The group consisted of NTSB's investigator-in-charge and representatives from FAA, Raytheon Aircraft, and Starflite Aviation. A transcript of the last 13 minutes of the CVR tape was prepared and made part of this report (see EXHIBITS).

The engines installed in N45BP were equipped with digital electronic engine controls (DEECs) with non-volatile memory chips. Both DEECs were recovered and, though substantially damaged, were shipped to Honeywell's Engines, Systems & Services (ES&S) Laboratory in Tucson, Arizona, where, on October 8, 2003, data was downloaded and analyzed under the auspices of FAA aviation safety inspectors. Data from the accident flight could only be retrieved from the right engine DEEC (see TESTS AND RESEARCH and EXHIBITS).

WRECKAGE AND IMPACT INFORMATION

The on-site investigation commenced on September 21 and terminated on September 24. Inspection revealed a water-filled crater that looked like the outline of an airplane, including its nose, wings, and forward fuselage. The crater was aligned on a magnetic heading of about 055 degrees. The airframe was extensively fragmented. The main body of wreckage, consisting of pieces of the cabin, aft fuselage, both engines, empennage, and cockpit roof were found within 25 feet of the initial impact crater. The separated landing gear legs were found buried in the mud in the crater. The landing gear was down. Only one flap actuator was recovered. Its extension corresponded to a flap setting of 25 degrees (approach flaps). Smaller pieces of wreckage (overwing emergency exit hatch, seats, seat cushions, and insulation) were strewn up a hill on a magnetic heading of 158 degrees. Both engines' fan blades were gouged and bent in the opposite direction of rotation, and some fan blades were separated in reverse bending. There were rotational scoring marks on both cases, spinners, and spinner supports. Metal spray was evident on both engines' third-stage low-pressure turbine blades.

Examination of various cockpit instruments revealed an airspeed indicator that registered 104 knots, an altimeter indicating 4,240 feet, and the flap indicator gauge that showed about 15 degrees down. Both engine Fan Speed gauges read approximately 29 per cent.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on all three pilots by a forensic pathologist at the Jefferson County Morgue, and FAA's Civil Aeromedical Institute (CAMI) performed toxicological screens on the three sets of specimens submitted. According to CAMI's reports, no ethanol was detected in muscle or brain tissue, and no drugs were detected in liver tissue. Carbon monoxide and cyanide tests were not performed.

TESTS AND RESEARCH

National Track Analysis Program (NTAP) radar data, DEEC data, and the CVR transcript were collated. Although NTAP data indicated the last known radar contact was at 1854:13, a primary contact was recorded at 1854:27 (no data tag attached). Time on the CVR transcript was based this primary contact, 1854:27, and worked backwards. Since DEEC data depicted only the last 51 seconds, it was manually transposed to the NTAP plot and CVR transcript.

No data from the accident flight was recov

NTSB Probable Cause

the first pilot's failure to maintain aircraft control and adequate airspeed. Contributing factors included performing intentional stalls at too low an altitude to afford a safe recovery, the pilot's failure to add power in an attempt to recover, and the flight instructor's inadequate supervision of the flight.