The NTSB recently opened its investigation docket on the Dec. 8, 2014, loss of an Embraer Phenom 100 (N100EQ) — an accident that renewed community worries and complaints about operations at Montgomery County Airpark (KGAI) in Gaithersburg, Maryland. The airport is a popular business aviation facility servicing metropolitan Washington, D.C.

Three persons — a mother and two young children — were killed when the EMB-500 jet crashed into trees and their home about 4,000 ft. from Runway 14. The owner-pilot and his two passengers also were killed. Weather was marginal VFR with a 2,000-ft. ceiling. The flight was considered an FAR Part 91 corporate flight.

The information below is taken from investigators’ reports posted in the accident docket.

On the day of the accident, the pilot contacted line personnel at Horace Williams Airport (IGX), Chapel Hill, North Carolina, informing them of a planned flight that morning. The airplane was subsequently topped off with 20 gal. of fuel per wing tank prior to departure. Airport personnel told investigators they saw the pilot seat himself in the left cockpit seat and a passenger take the copilot seat. An additional passenger was seated in the cabin. The airplane departed IGX at about 0945 on an IFR flight plan to Maryland.

The takeoff and cruise portion of the flight (at FL 230) progressed uneventfully. As the airplane let down toward Montgomery County Airpark, the pilot requested the RNAV (GPS) RWY 14 approach. 

The ATC controller cleared the airplane for the approach and authorized a frequency change to the uncontrolled airport’s advisory frequency.

The Automated Weather Observation System (AWOS) report at GAI about 6 min. prior to the accident was as follows:

METAR KGAI 081535Z 04006KT 10SM FEW021 OVC032 M01/M08 A3061 RMK AO1 GAI weather on the 8th at 1535 GMT/1035 EST, the wind was 040˚ at 6 knots (kt), visibility 10 statute miles, a few clouds at 2,100 feet (ft) above ground level (agl), an overcast cloud ceiling at 3,200 ft agl, temperature -1° Celsius (C), dew point -8°C, altimeter setting 30.61 inches of mercury. Remarks: automated observation system without a precipitation discriminator.

Performance data combined with the weather radar echoes indicated that the accident airplane was in IMC until approximately 1 mi. from GAI and also in conditions that were favorable for structural icing for at least 10 min. during the approach. Multiple jet air carriers in the vicinity of the accident site reported icing conditions in the clouds with cloud tops ranging from 4,300 ft. to 5,500 ft. above MSL. Four minutes after the accident, a regional turboprop pilot reported moderate mixed icing in the area between 4,000 and 5,000 ft. MSL.

Witnesses operating other airplanes at GAI reported that the ceiling was about 2,000 ft. and one of the witnesses reported seeing the accident airplane “break out” of the cloud layer during its final approach.

The airplane struck the ground and house about 900 ft. left of the extended runway, some 4,000 ft. from the approach end of Runway 14.

The Pilot

The 66-year-old owner-pilot held an ATP certificate with airplane-single-engine and multiengine land ratings. He also had an EMB-500 type rating and a letter of authorization for operation of the Aero Vodochody L-39, a Czech-built jet trainer. The PIC held a flight instructor certificate with ratings for single-engine airplanes. His PIC second-class medical certificate was issued on Feb. 7, 2014, with the limitations that he had to wear corrective lenses.

FAA records indicate that the pilot was involved in a previous accident at Montgomery County Airpark on March 1, 2010, involving a TBM 700. As a result of that accident the FAA reexamined the PIC on Aug. 19, 2010. The reexamination consisted of 1 hr. of oral examination and 1 hr. of flight examination, which included ILS approaches, missed approaches, go-arounds, balked landings and landings.

The pilot received an enforcement action for a Temporary Flight Restriction (TFR) violation that occurred on Aug. 18, 2011. FAA records indicated that the PIC was involved in a bird strike incident on Nov. 2, 2011, in a TBM 700 airplane. The airplane incurred no damage during the event.

The accident pilot received his EMB-500 type rating on April 28, 2014, after completion of a flight test administered by a designated pilot examiner. The flight test was accomplished in the accident airplane from the PIC’s home base of operations at Horace Williams Airport. He reported having 4,500 hr. of flight experience on his application for the type rating.

Training

The NTSB looked into the PIC’s training. It seems he had initially contacted Embraer on Nov. 18, 2013, and was enrolled in Phenom 100 Web-Based Training (WBT) to assist with the sale of an aircraft. On Jan. 12, 2014, the pilot toured the Embraer-CAE Training Services facility and met with a Phenom 100 instructor and Phenom sales representative. The pilot scheduled training on Feb. 18, 2014, for the Phenom 100 initial training course, but on Jan. 28, 2014, he canceled that training to pursue a type rating in the aircraft. At the time of the cancellation, he inquired about recurrent training with CAE. The pilot then scheduled Phenom 100 recurrent training for July 30, 2014, but on May 28, he called and canceled that training as well.

The Safety Board said it determined the PIC received training in the accident airplane from several different sources, and that the he flew the airplane on every flight since its purchase. The PIC reportedly received training from the seller of the airplane during its flight from France where it was purchased. The PIC then received training from Holland Aero, a company that provides transition and recurrent training in very light jets (VLJ), including the Phenom 100. The PIC initially contacted Holland Aero and requested a three-day transition course, but the proprietor advised that the PIC complete the nine-day course since the PIC had no previous experience in VLJ operations.

At the completion of the nine-day course, after about 21 hr. of flight instruction, the flight instructor did not feel that the PIC met the standards required for him to obtain a type rating for the airplane and advised him to receive more training.

The PIC returned home and was provided contact information for an instructor in his area. The PIC continued training with the new instructor in preparation for his flight check for the Phenom 100 type rating. The instructor reported that he provided training to the PIC that consisted mainly of improving his performance on procedures, approaches and maneuvers. The PIC received training on four consecutive days and an additional two days when the examiner was available. The training flights originated from IGX, but most of the training was done at Kinston Regional Jetport at Stallings Field (KISO), near Kinston, North Carolina, since it had longer runways and more instrument approach procedures. The instructor provided about 24 hr. of flight instruction with about 1 hr. of ground instruction prior to each flight.

On April 28, 2014, the PIC received a Phenom 100 type rating. The examiner who administered the flight check reported that the PIC exhibited no major deficiencies or flaws in his knowledge of the airplane during the oral examination. Prior to the flight examination, the examiner noted that the pilot’s home airport had a 4,000-ft. runway, which was unusual for the fleet but still within limits. He discussed this with the PIC and the importance of airplane control and stabilized approaches.

The examiner said the pilot recited industry approach standards that in instrument conditions with the airplane at 1,000 ft. AGL, or in visual conditions with the airplane at 500 ft. AGL, the airplane should be on glideslope, on target airspeed and configured for landing. 

The flight portion of the examination lasted 3.2 hr. and the examiner
noted that overall pilot performance was good and the PIC passed all Practical Test Standards. He didn’t remember any weakness in the pilot’s performance. 

In fact, he reported being impressed that the pilot handled the stabilized approach to IGX’s short runway well.

The examiner who administered the type rating check flight also conducted recurrent training with the pilot on Sept. 26, 2014. The examiner noted no deficiencies during that training and commented that he was impressed by the PIC’s handling of weather conditions that were present during the recurrent session.

The NTSB said the pilot’s electronic logbook revealed that he had accumulated 4,736.5 hr. total flight experience as of the last entry dated Nov. 20, 2014. The logbook indicated that the PIC’s flight time included about 1,500 hr. in Socata TBM 700 series airplanes, about 60 hr. in Aero Vodochody L-39C jets and 135.9 hr. in the Embraer Phenom 100, all of which occurred in N100EQ.

An autopsy and toxicology testing was conducted for the PIC. The autopsy report listed multiple injuries sustained in the accident as the cause of death. The toxicology report listed atorvastatin detected in liver samples. Atorvastatin is a lipid lowering medication marketed as Lipitor.

Icing Systems

The EMB-500 was equipped with an engine anti-ice system, and a wing and stabilizer deice system. The engine anti-ice system uses hot bleed air from the related engine compressor to remove or prevent ice formation around the engine inlet cowls. The wing and stabilizer deice system includes pneumatic deicing boots. Each wing has two separate deicing boots with one mounted on the outboard and the other mounted on the inboard section.

Each stabilizer has a single deicing boot on the leading edge. The boots are pneumatically inflated using bleed air from the engines. Both the engine anti-ice and the wing and stabilizer deice are controlled from the “Ice Protection” panel located at the lower edge of the main panel in front of the left pilot station.

When the “WINGSTAB” switch is selected to the ON position, the wing and stabilizer deice system begins a 1-min. cycle. This cycle starts with inflation of the horizontal stabilizer pneumatic boots for 6 sec., followed by the outboard wing pneumatic boots for 6 sec., and then the inboard wing pneumatic boots for six sec.

Inflation of the boots is followed by 42 sec. where none of the boots are inflated. If the “WINSTAB” switch remains in the ON position, the cycle repeats. A momentary activation of the switch results in the wing and stabilizer deice system performing one of the described cycles.

Operation in Icing Conditions

The Normal Procedures Section of the Airplane Flight Manual, Section 3 — Operation in Icing Conditions, includes these configuration elements:

 

AFTER TAKEOFF, CRUISE, DESCENT OR APPROACH

If TAT is below 10°C with visible moisture:

ENG 1 & 2 Switches......................... ON

The CAS messages A-I E1 (2) ON must be displayed (after a delay of approximately 10 seconds).

At the first sign of ice accretion in the airplane or if TAT is below 5°C with visible moisture:

WSHLD 1 & 2 Switches................... ON

ENG 1 & 2 Switches.......................... ON

WINGSTAB Switch......................... ON

The CAS messages A-I E1 (2) ON, D-I WINGSTB ON and SWPS ICE SPEED must be displayed after few seconds.

NOTE: If any of the above messages is not presented consider the associated system failed. Refer to the applicable Abnormal Procedure.

 

The AFM notes that “icing conditions may exist whenever the static air temperature (SAT) on the ground or for takeoff, or total air temperature (TAT) in flight, is 10C or below and visible moisture in any form is present (such as clouds, fog with visibility of 1 mi. or less, rain, snow, sleet and ice crystals).”

Investigators said that the flight data recorder (FDR) showed that the ice protection system was not activated at the time of the accident. It had been activated for about 2 min., approximately 39 min. prior to the end of the recorded data, when the airplane was at a pressure altitude of 23,000 ft. The final outside air temperature recorded by the FDR was 1.75C. The witness reports stating that the airplane broke out of the clouds during the approach are consistent with operation in visible moisture.

Stall Warning System

The accident airplane was equipped with a two-stage stall warning system consisting of an aural warning followed by a stick pusher. During a steady deceleration to stall the flight crew would receive an aural warning, and if the impending stall condition were not corrected, the stick pusher system would then activate. The stick pusher applies about 150 lb. of nose-down force to the yoke.

The stall warning system used airplane flap position, landing gear position, WINGSTAB switch position and Mach number to determine the angles of attack (AOA) at which the system triggers. These AOA values are then correlated to indicated airspeed and displayed as warning bands on the airspeed tape on the primary flight displays (PFD).

Selection of the airplane’s ice protection systems for the wings and horizontal stabilizer results in a stall warning at a lower AOA, and hence higher indicated airspeeds for the warning bands on the airspeed tape on the PFD.

Data from the airplane’s FDR indicated that for the configuration of the airplane at the time of the accident — landing gear down, flaps down at position-4 — the stall warning AOA would have been 21.0 deg. and 28.4 deg. for aural warning and stick pusher activation, respectively, with the ice protection system selected OFF. Warning would come at 9.5 deg. and 15.5 deg. for aural warning and stick pusher activation, respectively, with the ice protection system selected ON.

The final portion of the FDR data depicted the airplane’s approach to GAI. Performance data showed that the airplane experienced an aural stall warning at an indicated airspeed of 88 kt. At the time of the aural stall warning the airplane was at an altitude of 803 ft. MSL and on the final approach to the airport. The FDR had no parameter to record activation of the stick pusher.

Had the ice protection been activated, the pilot would have received an aural warning of impending stall about 20 sec. earlier, and the stick pusher would have activated about 5 sec. earlier.

Airspeed Display

The airplane was equipped with an electronic display system that included two PFDs, one for each pilot station. The PFD displayed airspeed, attitude, altitude, heading and slip/skid indicators in a standard “Basic T.” Core primary information was complemented with other communication, navigation, flight control, annunciation and planning information.

The airspeed information was displayed on the PFD in a vertical tape format, which was overlaid with additional airspeed information, including cues for low-speed awareness. The low-speed awareness indicators consisted of red and yellow bands and a green circle that moved in conjunction with the main speed tape. The top of the red band denoted the airspeed for aural stall warning activation, the top of the yellow band just above the red band marked a 3-kt. area prior to the activation of the aural stall warning, and the green circle denoted 1.3 times the speed at which stick pusher activation would be expected.

The positioning of the low-speed awareness cues was dependent on AOA measurements and airplane configuration, including the position of the WINGSTAB switch. When a change to airplane configuration was made, the low-speed awareness cues would be repositioned to reflect the current airplane configuration. Based on AOA measurements and the airplane’s configuration, with ice protection turned off during the landing approach at GAI, the airspeed tape display would have showed prior to autopilot disengagement the top of the red band at 86 kt., the top of the yellow band at 89 kt. and the green circle at 102 kt. With WINGSTAB ice protection turned on, the display would have showed the top of the red band at 102 kt., the top of the yellow band at 105 kt. and the green circle at 121 kt.

All of the forgoing will be considered by the NTSB members, who are likely to determine the “probable cause” of this tragic mishap sometime later this year. 

This article appears in the March 2016 issue of Business & Commecial Aviation magazine with the title "Phenom 100 Accident at Gaithersburg."