Original subtitles

NARRATOR: A business jet shuttling passengers to Akron, Ohio...

CAPTAIN OSCAR CHAVEZ: No, no, no, no, no!

NARRATOR: ...slams into a residential neighborhood

less than two miles from the runway.

911 Call: We have a plane into a house.

Heavy fire.

NARRATOR: There are no survivors.

Investigators search the wreckage but find few clues.

JIM SILLIMAN: The aircraft was burned down

to almost nothing on the hill.

NARRATOR: But a close examination of radar data provides a lead.

NTSB INVESTIGATOR: They’re cleared to descend

and then they wait a full two minutes.

Why?

SILLIMAN: We really wondered what is the situation in the cockpit at that time?

PASSENGER: Hey, you guys know where you’re going?

FIRST OFFICER RENATO MARCHESE: There's going to be some weather,

so I'd love to have you up here for the flight.

NTSB INVESTIGATOR: Whoa. Did you hear that?

PILOT (off screen): Mayday! Mayday!

Pull up!

(indistinct radio chatter)

♪♪

NARRATOR: ExecuFlight 1526 is climbing towards cruising altitude

over the US Midwest.

CAPTAIN CHAVEZ: Let's keep climbing with 1,500 feet per minute.

FIRST OFFICER MARCHESE: Roger.

NARRATOR: On board are seven executives

from a Florida-based property management company.

PASSENGER (off screen): Sorry.

NARRATOR: They’ve chartered the luxury jet from ExecuFlight,

a private carrier based in Fort Lauderdale.

Donnie Shackleford is a former captain

who flew with ExecuFlight.

DONNIE SHACKLEFORD: ExecuFlight caters to

the people of south Florida for business purposes.

Also to entrepreneurs, athletes and even entertainers.

CAPTAIN CHAVEZ: 17,000 feet.

FIRST OFFICER MARCHESE: Roger. 17,000 feet. Leveling off.

NARRATOR: ExecuFlight 1526 is flying

a short 35-minute flight northeast

from Dayton to Akron, Ohio.

First Officer Renato Marchese is the pilot

flying the twin engine Hawker 700.

He’s logged more than 4,000 hours

flying various private jets.

Captain Oscar Chavez is originally from Colombia

and has logged over 6,000 hours

flying private jets and cargo planes.

SHACKLEFORD: The captain had flown with me as a first officer.

He was a good pilot.

Oscar and Renato both seemed to enjoy flying a great deal.

It was a passion for both of them.

CAPTAIN CHAVEZ: Hey guys.

We’ve just reached our cruising altitude.

You know the drill.

We’ll be landing in Akron in half an hour.

PASSENGER: Anyone else want a drink?

SHACKLEFORD: The Hawker 700 passenger experience was more than comfortable.

They had a good galley.

Had plenty of headroom.

The interiors were updated. It was a very nice airplane.

PASSENGER: Cheers.

CONTROLLER: Zipline 15-26,

descend to 13-thousand.

NARRATOR: Zipline is ExecuFlight’s call sign.

CAPTAIN CHAVEZ: Descending to 13,000 feet.

Thank you. Zipline 15-26.

I’m gonna check the weather.

AUTOMATED WEATHER REPORT: Automated weather observation,

wind two niner zero at zero seven,

overcast 1,800,

temperature zero niner Celsius.

CAPTAIN CHAVEZ: All right.

We have overcast weather.

NARRATOR: The crew prepares for possible bad weather in Akron.

CAPTAIN CHAVEZ: Okay. Let's see.

Akron, right.

FIRST OFFICER MARCHESE: Heading?

CAPTAIN CHAVEZ: Two-forty-nine.

NARRATOR: Flight 1526 continues its descent.

Akron airport is less than 20 minutes away.

PASSENGER: I'm gonna go check to see where we're at.

Hey, you guys know where you’re going?

CAPTAIN CHAVEZ: You bet.

Look, it says right here on the chart.

FIRST OFFICER MARCHESE: I'd love to have you up here the whole time,

but there's going to be some weather,

so we can't be distracted.

SHACKLEFORD: It's not like the airlines where you have a closed door.

There's an open door.

I mean they can walk up to the cockpit and ask questions.

NARRATOR: As flight 1526 descends to 9,000 feet...

AUTOMATED WEATHER REPORT: Akron visibility one and a half

mist, sky condition overcast six hundred broken.

NARRATOR: ... the crew learns the weather in Akron is getting worse.

AUTOMATED WEATHER REPORT: Temperature one one Celsius.

NARRATOR: They need to know if it's still possible to land there.

CAPTAIN CHAVEZ: One and a half mile visibility.

FIRST OFFICER MARCHESE: What visibility does this approach want?

CAPTAIN CHAVEZ: One and a quarter miles.

All right, so we have visibility.

NARRATOR: Six minutes from Akron, the crew has a new distraction.

A flight instructor is teaching a student pilot

how to land in bad weather on the same runway

assigned to Flight 1526.

CONTROLLER (off screen): Zipline 1526,

we do have another aircraft that’s inbound to the airport

that is slower than you.

Fly heading 3-6-0.

Reduce speed one seven zero.

Descend and maintain 3000.

NARRATOR: The crew is asked to alter their course,

delay their descent and maintain their altitude

at 3,000 feet.

CAPTAIN CHAVEZ: Speed is one seven zero and 360.

Zipline 1526.

CONTROLLER: Zipline 1526, the Piper is on the ground.

You are cleared for localizer two-five approach.

CAPTAIN CHAVEZ (on radio): Cleared for localizer two-five. Thank you.

Zipline 1526.

NARRATOR: The Piper radios Flight 1526 with a weather update.

PIPER INSTRUCTOR (on radio): Hey guys,

we just landed on the localizer,

and broke out right at minimums.

CAPTAIN CHAVEZ: Appreciate it.

DAVID LAWRENCE: They said, "we broke out right at minimums,"

which means you're at the minimum

visibility necessary for the approach.

NARRATOR: Flight 1526 is now four miles from the runway

as it starts its final approach.

FIRST OFFICER MARCHESE: Can you check if I've got everything? Ignition?

CAPTAIN CHAVEZ: Everything is all set.

Standby.

NARRATOR: Two and a half miles from the airport,

the pilots are still searching for the runway.

Finally, the plane breaks through the clouds.

CAPTAIN CHAVEZ: Ground.

Keep going.

(plane roaring)

Okay, okay! Level out now!

FIRST OFFICER MARCHESE: I got it.

GPWS: Pull up. Pull up. Pull up.

PASSENGER: Hey, what's going on?

GPWS: Pull up. Pull up.

CAPTAIN CHAVEZ: No, no, no, no, no, no, no!

(screams)

(sirens wailing)

911 CALL: We have a plane into a house.

Heavy fire. We have a lot of wires down.

NARRATOR: ExecuFlight 1526 has crashed

into a two-story residential building.

Everyone onboard is dead.

The NTSB must now determine what caused this fatal accident.

ExecuFlight 1526 plunged into a residential neighborhood

in Akron, Ohio.

Incredibly, none of the residents

were home during the crash.

But the neighborhood is on edge.

MAN: You just don't think a plane would drop in a residential area like this.

This is crazy.

NTSB INVESTIGATOR: It looks like the left wing hit first.

NARRATOR: When NTSB investigators arrive on scene,

they notice a large gouge leading to the crash site.

LAWRENCE: One of the first things I noticed as I was walking up

was a large gouge in the front yard

in front of one of the townhomes.

It obviously told me that there was a control problem

with this airplane on the approach.

NTSB INVESTIGATOR: Flaps at 45.

NARRATOR: Investigators closely examine the wreckage

to determine how the plane was configured.

LAWRENCE: One of the things that we did learn very early on

was that the flaps were at a forty-five degree,

or full configuration, for this landing.

We knew they were trying to land.

NTSB INVESTIGATOR: So they’re configured to land,

and then they crash less than two miles

from the runway.

Why? Let’s take a look at the engines.

NARRATOR: Did the engines fail as the plane approached the airport?

NTSB INVESTIGATOR: It’s in pretty bad shape.

SILLIMAN: One of the things that we were looking for with the engines

at the accident site was if they were operating.

We really wanted to see if there was dirt,

concrete bits, that type of thing inside the engine.

NTSB INVESTIGATOR: Looks like, uh,

building insulation, and soil.

Okay.

SILLIMAN: Those gave us indications

that at impact these things were producing power.

NARRATOR: The NTSB is no further ahead

in solving the mystery of Flight 1526.

A team is dispatched to Air Traffic Control,

hoping the controller can provide some insight.

CONTROLLER: No Mayday call.

Nothing unusual.

Oh well, they were delayed by a Piper that was ahead of them.

I instructed them to change heading, reduce speed,

and maintain 3,000 until cleared,

which I did at, uh, 14:49:22 when they were five miles out.

Zipline 1526, the Piper is on the ground,

you are cleared for localizer two five approach.

The Piper didn’t affect their landing.

NARRATOR: The Piper was on the ground

when the business jet was still about five miles

from the airport,

ample distance for a safe landing.

At the crash site,

investigators comb through the wreckage for more clues.

LAWRENCE: What I needed to know

was was there anything in the accident wreckage

that was recoverable from an operational standpoint?

The material that the pilots use, the cockpit,

things that could be documented, that's what I wanted to see.

NTSB INVESTIGATOR: Hey, check this out.

LAWRENCE: We found manuals

that the pilots were required to have onboard.

NTSB INVESTIGATOR: Yeah. This is something.

Grab an evidence bag.

LAWRENCE: It was damaged, and it was burnt,

but we were able to examine it.

NARRATOR: Investigators then make their most significant discovery so far.

LAWRENCE: We found the angle of attack indicator in the cockpit wreckage.

That's important because at a certain angle of attack

the wing will stall.

NTSB INVESTIGATOR: Now, what angle were you at?

LAWRENCE: It was damaged extensively.

But I could see that the needle was in the red band.

JOHN NANCE: When the angle of attack

indicates it's in the red, you're stalled.

In other words, this wing was no longer flying.

It's as simple as that.

NARRATOR: Investigators determine that the plane stalled

as it approached the airport.

Now they must understand why.

GPWS: Pull up. Pull up.

NTSB INVESTIGATOR: That’s great. Get that to Washington.

NARRATOR: The cockpit voice recorder from ExecuFlight 1526 is recovered

and sent to NTSB headquarters for analysis.

LAWRENCE: When we found out the aircraft did have a cockpit voice recorder,

the first thing we were very interested in doing

is making sure it got back to our labs.

I didn't know if we had good information.

NARRATOR: The CVR is doubly important in this case

since the Hawker 700 wasn't equipped

with a Flight Data Recorder.

NANCE: Flight data recorders are incredibly important

because they give us a no question look

at precisely what the flight dynamics

were all the way to impact.

LAWRENCE: These investigations are like a jigsaw puzzle,

and with a flight data recorder,

the pieces of the puzzle are much bigger

and easier to put together.

By not having a flight data recorder,

it didn't give us a whole lot of information early on

in the investigation.

NARRATOR: While investigators wait for the voice recording,

they work with what they have:

the documents found in the cockpit wreckage.

NTSB INVESTIGATOR: The weight and balance.

Will you look at that?

LAWRENCE: We found that the weight and balance

didn't account for the auxiliary power unit.

It's a, uh, little jet engine in the back

that helps power the aircraft when it's on the ground.

NTSB INVESTIGATOR: So they had no APU.

NARRATOR: The team wonders how this compares

to what they discovered at the crash site.

NTSB INVESTIGATOR: Hello, APU.

LAWRENCE: We saw that the APU was onboard

‘cause we found it in the wreckage.

NTSB INVESTIGATOR: It looks like they were carrying more weight than they thought.

NARRATOR: Investigators believe they’ve found an error

in the plane’s documented weight and balance.

NTSB INVESTIGATOR: Were they too heavy?

I wonder how much this plane truly weighed.

NARRATOR: The pilots made their calculations

without accounting for an APU,

but there clearly was one onboard.

SILLIMAN: We certainly had a concern

about whether or not the airplane

was within its weight and balance.

NARRATOR: The NTSB calculates the actual weight of the plane

during its final flight.

NTSB INVESTIGATOR 2: The APU weighs 300 pounds.

NTSB INVESTIGATOR: And according to the aircraft refueler,

they were loaded with 8160 pounds of fuel,

but they only wrote down 7700.

So how much in total were they over by?

Ah, they were only 286 pounds overweight.

NARRATOR: The plane’s actual weight was slightly more

than what the pilots recorded.

LAWRENCE: It wouldn't have really made

a performance difference on the aircraft.

NARRATOR: The weight of the APU and the additional fuel

was not enough to affect the balance of the airplane.

LAWRENCE: But it did tell us that this crew and this company

wasn't following their procedures appropriately.

Somebody wasn't watching what they were supposed to be doing.

NARRATOR: Investigators need to look elsewhere

to explain why Flight 1526 stalled.

SILLIMAN: We knew that there was not a flight data recorder on this airplane,

so that's frustrating because

we don't have the precise details about the airspeed,

the altitude and the attitude of the aircraft.

NARRATOR: To solve the case,

the NTSB begins compiling what data they do have,

the radar data from air traffic control.

NTSB INVESTIGATOR: Show me what you've got so far.

SILLIMAN: A turning point in our investigation came

when our engineer was able to recreate our aircraft performance

from the radar data.

NTSB INVESTIGATOR: Okay. They're 150 knots

four minutes before the crash.

Keep going.

SILLIMAN: Our aircraft performance expert

was able to estimate the airspeed of the airplane,

the angle of attack, the attitude,

the altitude and rate of descent.

NTSB INVESTIGATOR: As the plane approached the airport,

you expect the airspeed to decrease.

It drops from 300 down to 150.

Everything normal.

NARRATOR: Investigators find nothing unusual about the flight,

until they focus on the last two minutes.

NTSB INVESTIGATOR: Look here.

The speed drops to 130 knots

and then it keeps dropping to 98 knots.

No wonder they stalled.

SILLIMAN: The thing that really stood out

was the excessive rate of descent at the very end

was at 98 knots,

which was gonna stall the airplane.

NANCE: Airspeed is life.

This is one of the most important points

in flying any airplane but especially,

especially a jet.

NTSB INVESTIGATOR 2: Maybe they were trying to stay clear of the Piper?

NTSB INVESTIGATOR: I doubt it.

The controller told them the runway was clear

three minutes before it stalled.

NARRATOR: The airspeed data leaves investigators with more questions.

NTSB INVESTIGATOR: Let's look at the altitude data.

NARRATOR: The team reviews the plane’s descent profile

for the period leading up to the crash.

NTSB INVESTIGATOR: The early part of the descent looks pretty normal.

They're doing a dive-and-drive approach.

They level off at 9000, 5000, 4000.

Look at that. That's odd. Can you blow that up?

NARRATOR: They make an important discovery.

NTSB INVESTIGATOR (off screen): Look.

They hold at 3000 feet for an entire two minutes.

That's way too long.

And then they plunge steeply.

Bring up the final approach they were supposed to take.

It's not even close.

LAWRENCE: On normal approaches,

the glide path allows the airplane to descend

on a gentle three-degree path all the way down to the runway.

NTSB INVESTIGATOR: It looks like they started

their final approach too late.

NTSB INVESTIGATOR 2: And then have to race to catch up.

NARRATOR: The data shows that after delaying their approach,

the pilots descended very steeply

and at twice the normal rate.

LAWRENCE: Once they started diving the airplane down to 2,000 feet a minute

to get to that lower altitude,

that approach was unstable,

and at that point in time

they should have executed a go around.

NTSB INVESTIGATOR 2: The controller told us

they acknowledged his instruction to descend.

CONTROLLER: Zipline 15-26,

the Piper is on the ground.

You are cleared for localizer two five approach.

CAPTAIN CHAVEZ: Cleared for localizer two five.

Thank you.

NTSB INVESTIGATOR: They're cleared to descend

and then they wait a full two minutes.

Why?

SILLIMAN: We really wondered what is the situation in the cockpit at that time?

NARRATOR: NTSB Investigators turn to the cockpit voice recorder

from Flight 1526 to understand

why the pilots delayed their final descent into Akron.

NTSB INVESTIGATOR: Take it from the first instruction about that Piper.

CONTROLLER (on radio): Zipline 1526,

we do have an aircraft inbound to the airport

that is slower than you.

Fly heading 3-6-0.

Reduce speed one-seven-zero.

Descend and maintain 3000.

CAPTAIN CHAVEZ (off screen): Down to 3000,

one seven zero is the speed and 360.

Zipline 1526. Down to 3000.

He wants 170 knots.

FIRST OFFICER MARCHESE: Okay, I'll have to drag everything.

LAWRENCE: Somebody lowered the landing gear

to start slowing the airplane up

and creating drag to hopefully get a little bit more spacing

between them and the other airplane.

CAPTAIN CHAVEZ: Did you hear what he said?

There’s another plane on the approach.

He's slower than us.

We don't know if he's on the ground yet.

LAWRENCE: The captain was very concerned

about the spacing between them and the training flight

and was saying that to the co-pilot.

(airplane engines slow)

NTSB INVESTIGATOR: Did you hear that?

NARRATOR: Investigators hear the sound of the engine thrust decreasing.

NTSB INVESTIGATOR: Let's see the airspeed again.

The airspeed drops from 170

down to 140.

That is way slower than he needs to be going.

CAPTAIN CHAVEZ: Look, you’re going 140.

CONTROLLER (on radio): Zipline 1526, the Piper is on the ground.

You are cleared for localizer two-five approach.

CAPTAIN CHAVEZ: Cleared for localizer two-five.

Thank you.

NARRATOR: Flight 1526 is now at 3,000 feet

and positioned to fly straight into Akron airport.

NTSB INVESTIGATOR: They should start their descent.

NARRATOR: Why did the pilots delay their descent for two minutes,

forcing them to catch up?

CAPTAIN CHAVEZ: You're going one-twenty.

You can't keep decreasing your speed.

LAWRENCE: Once the copilot received the warning from the captain

that they were too slow,

the co-pilot should have increased thrust significantly.

NARRATOR: But instead, the pilots get into a debate.

FIRST OFFICER MARCHESE: No. One-twenty. Where did you get one-twenty?

It's more like one-twenty-five,

which is the approach speed.

CAPTAIN CHAVEZ (off screen): But you've still got the flaps to go.

FIRST OFFICER MARCHESE: And when they go down...

CAPTAIN CHAVEZ: This is what I'm saying.

If you continue decreasing your speed...

FIRST OFFICER MARCHESE: But why?

CAPTAIN CHAVEZ: Because we're gonna stall! I don't wanna stall!

FIRST OFFICER MARCHESE: How do we...?

NTSB INVESTIGATOR (off screen): Stop.

They are so busy arguing about their speed

that they forget to start their descent.

SILLIMAN: There was about two minutes of conversation

concerning the airplane's speed.

The pilot and first officer were actually arguing

that it was getting too slow.

NANCE: That delay of almost two minutes was critical.

He's already too slow,

and he's overflown the altitude he should be at,

and now they've got to chase the approach.

Now he's got to get the airplane down fast.

NTSB INVESTIGATOR: Okay.

NARRATOR: What investigators hear next is even more shocking.

PIPER INSTRUCTOR: Hey guys, we just landed on the localizer

and broke out right at minimums.

SILLIMAN: They were notified that the small airplane

had landed safely on the runway.

FIRST OFFICER MARCHESE: Full flaps.

NTSB INVESTIGATOR (off screen): Stop.

Full flaps at that speed? What was he thinking?

Bring up the altitude graph again.

NTSB INVESTIGATOR 2: Well hey,

that's why the plane starts to drop like a rock.

NARRATOR: The team finally understands why Flight 1526

ended up in a 2,000 feet per minute descent,

twice the recommended rate.

The First Officer was racing to get the plane back on course.

SILLIMAN: The airplane is too high,

it's too slow,

and with full flaps rather than partial flaps.

They really needed to get down in a hurry,

and really that is our turning point when we said

this airplane is not configured properly for the approach,

and this puts the crew and passengers

in really a lot of danger.

NTSB INVESTIGATOR: He should have just called a missed approach and tried again.

NARRATOR: Investigators now need to understand

why the pilots continued their dangerous descent.

SILLIMAN: When we look at the errors that the pilots made,

we really had to wonder: What was their background?

NARRATOR: NTSB Investigator Sathya Silva examines

the pilots' personnel records to see

if they explain their behavior on the day of the accident.

SATHYA SILVA: The First Officer had more

than 4000 hours of flight time.

He was the pilot in command for 3200 hours,

and he passed all his courses.

NTSB INVESTIGATOR (off screen): Health?

SILVA: He... yeah, he just turned 50.

No sign of drug or alcohol in his system.

But take a look at this.

It looks like he pulled an all-nighter two nights before the accident.

Could he have been fatigued?

LAWRENCE: For the first officer

what we found was he did not have

the rest several days earlier that the regulations required.

NTSB INVESTIGATOR: Let's see what the airline has to say.

LAWRENCE: So we wanted to take a look

and see if a chronic fatigue problem

may have manifested itself several days later,

to hopefully explain why this crew

and particularly the first officer

was making so many mistakes.

SILVA: Thanks for coming in.

SHACKLEFORD: Happy to help out.

NARRATOR: Silva interviews ExecuFlight captain Donnie Shackleford,

who had flown with First Officer Marchese

leading up to the crash.

SILVA: Tell me about your last flight

with the First Officer.

SHACKLEFORD: Uh, two days before the accident

we flew into Fort Lauderdale.

FIRST OFFICER MARCHESE: They want me to fly to Mexico overnight, like now.

SHACKLEFORD: That would be fine to go

considering the duty time issue,

as long as they remained overnight in Mexico.

SILVA: So did he sleep overnight in Mexico?

SHACKLEFORD: Nope.

Came right back to Fort Lauderdale.

I talked to him the night before the crash.

He told me that he was worn out from the other trip.

Even though he was legal as far as the number of hours between,

he was not rested.

He should not have been on that flight.

SILVA: The fact that the First Officer

had to fly an overnight flight and not sleep when his body

wanted to sleep resulted in circadian disruption.

NANCE: We know that human beings have limits.

If you’re not getting the appropriate sleep over time,

your attitude can go to heck in a hand basket,

and that can crash airplanes.

NARRATOR: Because the First Officer did have the required

amount of sleep the night before the crash,

investigators can't definitively point to sleep deprivation

as the cause of their poor decision making.

There’s something about the flight

that still troubles Silva.

SILVA: How often would

the First Officer be the pilot flying?

SHACKLEFORD: Only if there were no paying passengers.

- SILVA: Why? - SHACKLEFORD: Company policy.

SILVA: The company did have

a procedure to enable the first officers

to get experience flying the aircraft,

and those were in empty legs

where passengers weren't on board.

SHACKLEFORD: Renato should not have been flying.

It should have been Oscar.

NARRATOR: Silva discovers that the captain

violated standard operating procedures.

LAWRENCE: What we don't know,

and what is a little confusing, is why in this case,

when you had passengers in the back,

you had weather that was gonna be a factor,

and an approach that was gonna be relatively challenging,

why this captain decided to allow his first officer to fly.

NARRATOR: The NTSB wants to know why Captain Chavez

broke company policy,

allowing his first officer to fly the plane

with clients onboard.

SILVA: Take a look at this.

The Captain didn't get much sleep either.

He got a full night's sleep before the crash,

but he didn't get a full eight hours

for four nights before that.

Maybe he was also fatigued.

NTSB INVESTIGATOR: That's possible.

SILVA: As we looked further back into his records,

it looks like the days prior he actually only averaged

about six hours of sleep.

NARRATOR: Investigators listen for any indication of fatigue

on the cockpit voice recorder.

NTSB INVESTIGATOR: Let's pick up where we left off,

the start of the final descent.

NARRATOR: Descending from 3,000 feet,

the crew begins their landing checklist.

FIRST OFFICER MARCHESE: Can you check if I've got everything? Ignition?

CAPTAIN CHAVEZ: Everything is all set.

Standby... Yaw damper... autopilot... main air valves.

NTSB INVESTIGATOR: He just stops in the middle

of his landing checklist.

SILVA: It's, it's like he's distracted.

LAWRENCE: There were checklists

that were supposed to be done all the way through.

And we found on the cockpit voice recorder

all of the checklists that they should have complied with were never completed.

NARRATOR: Instead of finishing the checklist,

the captain’s focus turns to the plane’s erratic descent.

CAPTAIN CHAVEZ (off screen): You're diving. Don't dive.

Two thousand feet per minute.

- Buddy. - FIRST OFFICER MARCHESE: Yeah.

CAPTAIN CHAVEZ: Two thousand feet per minute!

Don't go two thousand feet per minute! You with me there?

LAWRENCE: The co-pilot was being coached

so much by this captain that at this point -

this is the very serious portion of the approach -

you're gonna go down into weather that's very low

and very significant.

The captain should have taken control.

NANCE: When it's time for the captain to say, I got the airplane

‘cause you're not performing well enough,

there should be no question and no hesitation.

NTSB INVESTIGATOR: Why wouldn't he take over?

NARRATOR: Investigators hear more than the effects of fatigue

on the recording.

LAWRENCE: By having the first officer fly,

this captain then was dividing his time being a captain

and also being an instructor.

We found he wasn't appropriately managing the cockpit as a captain.

CAPTAIN CHAVEZ: Don't go 2000 feet per minute when you are 500 feet

above the ground!

NTSB INVESTIGATOR: Bring up the altitude graph again.

They're less than 500 feet off the ground.

That's below their minimum descent altitude.

LAWRENCE: It's critical that you do not descend below that altitude

until you have a visual view of the airport or the runway.

NARRATOR: But they continue to descend.

CAPTAIN CHAVEZ: Ground.

NTSB INVESTIGATOR: God. He, he can see the ground, but not the runway.

NANCE: They're coming down from three thousand feet,

and they've got to get to the minimum descent altitude,

which is only five hundred feet above the ground.

There's not much room to work with here if you screw this up.

CAPTAIN CHAVEZ: Keep going.

NARRATOR: The CVR reveals that the Captain violated a fundamental rule

by continuing the descent without the runway in sight.

NANCE: If you don't see the field

then you do a go-around.

NARRATOR: Because the pilots were still looking for the airport

while descending below minimum altitude,

neither of them noticed their decaying airspeed.

CAPTAIN CHAVEZ: Okay level off now!

FIRST OFFICER MARCHESE: Got it.

GPWS: Pull up. Pull up.

NANCE: They'd been too slow for the last little while

and they don’t recognize even with a stick shaker banging away

that they are in an aerodynamic stall.

GPWS: Pull up. Pull up.

NANCE: That doomed them.

NARRATOR: They weren’t able to recover from the stall.

CAPTAIN CHAVEZ: No, no, no, no, no, no!

NTSB INVESTIGATOR: It was a perfect storm

of their own making.

NARRATOR: Investigators find enough evidence on the voice recording

to conclude that fatigue was likely one component

of the crew’s poor decision making.

SILVA: We found that the captain's behavior

could have been attributed to fatigue.

NARRATOR: But fatigue alone doesn't explain the long list

of botched procedures on Flight 1526.

SILVA: They broke so many rules

it makes you wonder who trained them.

LAWRENCE: They weren't following their procedures.

They missed checklists and callouts.

They got delayed on the approach.

They were flying in the wrong configuration.

We decided to go back and take a look at their training.

What was it that led up to them making these mistakes?

NARRATOR: The NTSB orders up the employment

and training records of the crew of Flight 1526

for the last five years.

SILVA: You're not gonna believe this.

NARRATOR: They are shocked by what they find.

SILVA: The captain’s termination notice

says that he was fired from his last job.

NARRATOR: Investigators learn that the Captain was dismissed

because he failed to show up for training.

NTSB INVESTIGATOR: Get this.

The First Officer was terminated

because his performance was below standard.

NARRATOR: The First Officer was let go

because he struggled during flight training.

SILVA: Both these guys had training issues

and were fired because of them, and ExecuFlight knew about it.

NANCE: The captain's prior employment

was suspect in terms of why was he dismissed.

The first officer's hiring in this particular case

smacks of just warm body hiring,

having somebody with at 98 degree temperature put in the right seat

and say, we've got a co-pilot ‘cause he's licensed.

NTSB INVESTIGATOR: So, why did ExecuFlight

hire these guys?

SILVA: We start to wonder: Did the company know

about these deficiencies?

If they did, did they address them?

Okay, thanks again. Bye.

I just got off the phone with the president.

He said he knew about their history but hired them anyway.

The President of ExecuFlight stated that he had hired the captain

because of his extensive experience

in the Hawker aircraft,

as well as flights that he had personally taken

with the captain prior to his employment.

The First Officer was hired based on a recommendation

from another pilot,

as well as one flight that he had taken with him personally.

He said they didn't contact their previous employers.

NANCE: It is very, very important

in hiring a pilot to do what the law says,

do what the regulations say,

contact the previous employers and have an opportunity to know

if this individual has some bad habits

that you certainly don't want in your operation.

SILVA: ExecuFlight did give them CRM training.

LAWRENCE: Basically, Cockpit Resource Management training

is teaching pilots to work as a team

and using all their available tools together

so they are operating as one.

NARRATOR: But when the investigators

examine the airline's CRM training program,

they are underwhelmed.

SILVA: Not much of a training manual.

LAWRENCE: The regulations required

ExecuFlight to have cockpit resource management training,

and they did.

What we found was their training was insufficient,

and their evaluation of the crew was not proper.

SILVA: This was an accident waiting to happen.

CAPTAIN CHAVEZ: No, no, no, no, no, no!

NARRATOR: The NTSB concludes that the probable cause of the crash

was the crew’s mismanagement of their approach,

deviation from operating procedures,

and ExecuFlight’s lax hiring and training practices.

SILLIMAN: We determined that ExecuFlight did not enforce

and did not make sure that the pilots were following

standard operating procedures.

NARRATOR: In their report, the NTSB makes several recommendations

for private operators like ExecuFlight.

They include better training for pilots

on non-precision approaches like the one into Akron,

and the installation of flight data recorders

that could also be used to monitor

the progress of their flights.

SILLIMAN: The NTSB recommendations really comes down

to what kind of scrutiny you have on your pilots.

Do you know what's going on in your cockpit?

Do you know what your pilots are doing?

NANCE: Standard Operating Procedures,

these are incredibly important.

It's like we say: Airspeed is life.

Well, adherence to Standard Operating Procedures is life.

And if you begin to remove that structure,

you go back in time and you lose the benefit of all the lessons

that we have paid so dearly for in the past by crashes.

Captioned by Point.360