All language subtitles for Air.Disasters.S16E02.Playing.Catch.Up.1080p.AMZN.WEB-DL.DDP.2.0.H.264-OGRE_track4_[eng]

[Chavez] No, no, no, no, no, no!

[Narrator] ... slams into
a residential neighborhood

less than two miles from the runway.

[911 Caller] We have a plane into a house.
Heavy fire.

[Sirens]

[Narrator] There are no survivors.

Investigators search the
wreckage, but find few clues.

The aircraft was burned down
to almost nothing on the hill.

[Narrator] But a close examination
of radar data provides a lead.

They're cleared to descend,

and then they wait a full two minutes.

Why?

We really wondered,

what is the situation
in the cockpit at that time?

[Passenger] Hey,
you guys know where you're going?

There's going to be some weather, so,

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

Whoa. Did you hear that?

[Woman] Ladies and Gentlemen,
we are starting our approach.

[Man] We lost both engines.

[Woman] A mask over your nose.
Emergency descent.

-[Man] Mayday, mayday!
-[Woman Shouting]

[Crashing]

[Man] It's gonna crash!

[Narrator] ExecuFlight 1526

is climbing towards cruising
altitude over the Midwest.

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

Roger.

[Narrator] On board are seven executives

from a Florida-based
property management company.

[Laughs] 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.

[Shackleford] ExecuFlight
caters to the people

of south Florida for business purposes.

Also to entrepreneurs,
athletes and even entertainers.

17,000 feet.

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.

Hey, guys. We've just reached
our cruising altitude.

You know the drill.

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

Anyone else want a drink?

[Shackleford] The Hawker
700 passenger experience

was more than comfortable.
They had a good galley.

Had plenty of head room.

The interiors were updated.

It was a very nice airplane.

Cheers.

Zipline 1526, descend to 13,000.

[Narrator] Zipline is
ExecuFlight's call sign.

Descending to 13,000 feet.

Thank you. Zipline 1526.

Let me check the weather.

[Automated Voice]
Automated weather observation,

wind two niner zero at zero seven,

overcast 1800,

emperature zero niner Celsius. t

All right. We have overcast weather.

[Narrator] The crew prepares
for possible bad weather in Akron.

Okay, let's see.

Akron, right.

-Heading?
-Two-forty-nine.

[Narrator] Flight 1526
continues its descent.

Akron airport is less
than 20 minutes away.

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

Hey, you guys know where you're going?

[Laughs] You bet.

Look, it says right here on the chart.

[Chuckles] 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.

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 Voice] 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 Voice]
Temperature one one Celsius.

[Narrator] They need to know

if it's still possible to land there.

One and a half mile visibility.

What visibility does this approach want?

One and a quarter miles.

All right, so we have visibility.

[Narrator] ix minutes from Akron,
S he crew has a new distraction. t

A flight instructor
is teaching a student pilot

how to land in bad weather

on the same runway
assigned to Flight 1526.

[Controller] 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 1-7-0.
Descend and maintain 3000.

[Narrator] The crew is asked
to alter their course,

delay their descent

and maintain their altitude at 3,000 feet.

Speed is 1-7-0 and 360.

Zipline 1526.

Zipline 1526, the Piper is on the ground.

You are cleared
for localizer 2-5 approach.

[Chavez] Cleared for localizer 2-5.
Thank you.

Zipline 1526.

[Narrator] The Piper radios
Flight 1526 with a weather update.

[Woman] Hey guys,
we just landed on the localizer,

and broke out right at minimums.

Appreciate it.

[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.

Can you check if I've got everything?

Ignition?

[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.

Ground!

Keep going.

Okay, okay, level out now!

[Marchese] I got it.

-[Automated Voice] Pull up! Pull up!
-[Beeping]

Pull up!

Hey, what's going on?

-[Automated Voice] Pull up! Pull up!
-[Rattling]

-No, no, no, no, no, no, no!
-[Screaming]

[Sirens]

[911 Caller] We have a plane into a house.
Heavy fire.

We have a lot of wires down.

[Sirens]

[Narrator] ExecuFlight 1526 has crashed

into a two-story residential building.

Everyone on board is dead.

he NTSB must now determineT
hat caused this fatal accident. w

[Sirens]

[Narrator] xecuFlight 1526
plungedE nto a residential neighborhoodi

in Akron, Ohio.

Incredibly, none of the residents

were home during the crash.

But the neighborhood is on edge.

You just don't think a plane would drop

in a residential area
like this. This is crazy.

It looks like the left wing hit first.

[Narrator] When NTSB
investigators arrive on the scene,

they notice a large gouge
leading to the crash site.

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 town homes.

It obviously told me that
there was a control problem

with this airplane on the approach.

Flaps at 45.

[Narrator] Investigators
closely examine the wreckage

to determine how the plane was configured.

[Lawrence] ne of the thingsO
hat we did learn very early ont

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

or full configuration, for this landing.

We knew they were trying to land.

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?

It's in pretty bad shape.

One of the things that we were looking for

with the engines at the accident site

was that they were operating.

We really wanted to see if
there was dirt, concrete bits,

that type of thing, inside the engine.

Looks like, uh, building insulation

and soil.

[Whispers] Okay.

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.

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 3000 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
2-5 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.

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.

[Investigator] Hey, check this out.

We found manuals that

the pilots were required to have on board.

[Investigator] 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.

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.

Now, what angle were you at?

[Lawrence] It was damaged extensively,

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

When the angle of attack
indicates it's in the red,

you're stalled.

n other words, I
his wing was no longer flying. t

It's as simple as that.

[Narrator] Investigators
determine that the plane stalled

as it approached the airport.

Now they must understand why.

[Automated Voice] Pull up! Pull up!

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
that 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.

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.

The weight and balance.

Will you look at that?

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.

So, they had no APU.

[Narrator] The team
wonders how this compares

to what they discovered at the crash site.

Hello, APU.

We saw that the APU was on board,

'cause we found it in the wreckage.

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.

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 on board.

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.

The APU weighs 300 pounds.

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.

It wouldn't have really made
a performance difference

on the aircraft.

[Sighs]

[Narrator] The weight of the APU

and the additional fuel

was not enough to affect

the balance of the airplane.

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.

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.

Show me what you got so far.

A turning point in our investigation

came when our engineer
was able to recreate

our aircraft performance
from the radar data.

[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.

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.

Look here. The speed drops to 130 knots

and then it keeps dropping to 98 knots.

No wonder they stalled.

[Silliman] he thing that really stood outT

was the excessive rate of descent

at the very end was 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.

Maybe they were trying
to stay clear of the Piper?

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.

Let's look at the altitude data .

[Narrator] The team reviews
the plane's descent profile

for the period leading up to the crash.

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.

[Investigator] Look. They hold
at 3,000 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.

It looks like they started
their final approach too late.

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.

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.

The controller told us

they acknowledged
his instruction to descend.

Zipline 1526, the Piper is on the ground.

You are cleared
for localizer 2-5 approach.

Cleared for localizer 2-5. Thank you.

They're cleared to descend,

and then they wait

a full two minutes.

Why?

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

heir final descent into Akron. t

Take it from the first
instruction about that Piper.

[Controller] Zipline 1526,

we do have an aircraft
inbound to the airport

that is slower than you.

Fly heading 3-6-0. Reduce speed 1-7-0.

Descend and maintain 3000.

Down to three thousand, 1-7-0
is the speed, and 360.

Zipline 1526.

Down to 3000. He wants 170 knots.

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.

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.

[Investigator] Did you hear that?

[Narrator] Investigators hear the sound

of the engine thrust decreasing.

Let's see the airspeed again.

The airspeed drops from 170 down to 140.

That is way slower
than he needs to be going.

Look, you're going 140.

[Controller] Zipline 1526,
the Piper is on the ground.

You are cleared
for localizer 2-5 approach.

Cleared for localizer 2-5. Thank you.

[Narrator] Flight 1526
is now at 3,000 feet

and positioned to fly
straight into Akron airport.

They should start their descent.

[Narrator] Why did the pilots
delay their descent for two minutes,

forcing them to catch up?

You're going 120.

You can't keep decreasing your speed.

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.

No. 120. Where did you get 120?

It's more like 125,
which is the approach speed.

But you've still got the flaps to go.

-And when they go down...
-This is what I'm saying.

If you continue decreasing your speed...

But why?

Because we're gonna stall!
I don't wanna stall!

How do we...? Uh.

[Investigator] 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.

Okay.

[Narrator] What investigators hear next

is even more shocking.

[Woman] Hey guys,
we just landed on the localizer

and broke out right at minimums.

They were notified that the small airplane

had landed safely on the runway.

Full flaps.

[Investigator] Stop.

Full flaps at that speed?
What was he thinking?

Bring up the altitude graph again.

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.

he First Officer was racing toT
et the plane back on course. g

[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 a turning
point when we said

his airplane is not configuredt
roperly for the approach, p

and this puts the crew and passengers

in really a lot of danger.

He should have just called a
missed approach, 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.

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.

[Investigator] Health?

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-niter

two nights before the accident

Could he have been fatigued?

For the first officer what we found was

he did not have the rest
several days earlier

that the regulations required.

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.

Tell me about your last flight
with the First Officer.

Uh, two days before the accident

we flew into Fort Lauderdale.

[Ringing]

They want me to fly to Mexico overnight.

Like, now.

That would be fine to go

considering the duty time issue,

as long as they remained
overnight in Mexico.

So, did he sleep overnight in Mexico?

Nope. Came right back to Fort Lauderdale.

[Shackleford] 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.

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,

nvestigators can't definitivelyi
oint to sleep deprivationp

as the cause of their poor
decision making.

There's something about the flight

that still troubles Silva.

How often would the First
Officer be the pilot flying?

Only if there were no paying passengers.

Why?

Company policy.

The company did have a procedure to enable

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've been Oscar.

[Narrator] Silva
discovers that the captain

violated standard operating procedures.

[Lawrence] hat we don't know,
W nd what is a little confusing, a

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,

hy this captain decided tow
llow his first officer to fly. a

[Narrator] The NTSB wants
to know why Captain Chavez

broke company policy,

allowing his first officer
to fly the plane

with clients on board.

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.
-That's possible.

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.

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.

Can you check if I've got everything?

Ignition?

Everything is all set.

Stand-by.

Yaw damper.

Autopilot, main air valves.

He just stops.

In the middle of his landing checklist.

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

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've complied with

were never completed

[Narrator] Instead of
finishing the checklist,

he captain's focus turnst
o the plane's erratic descent. t

[Chavez] You're diving. Don't dive.

2,000 feet per minute.

-Buddy.
-Yeah.

2,000 feet per minute!
Don't go 2,000 feet per minute!

You with me there?

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.

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.

Why wouldn't he take over?

[Narrator] Investigators hear
more than the effects of fatigue

on the recording.

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.

Don't go 2,000 feet per minute

when you are 500 feet above the ground!

[Investigator] Bring up
the altitude graph again.

They're less than 500 feet off the ground.

That's below their minimum
descent altitude.

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.

Ground!

God. He, he can see the ground,

but not the runway.

They're coming down from 3,000 feet,

and they've got to get it to

the minimum descent altitude,

which is only 500 feet above the ground.

here's not much room to workT
ith here if you screw this up. w

Keep going.

[Narrator] The CVR reveals

that the Captain violated
a fundamental rule

by continuing the descent
without the runway in sight.

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.

Okay, level out now!

Got it! [Grunts]

[Loud Rattling]

[Automated Voice] Pull up! Pull up!

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.

[Automated Voice] Pull up! Pull up!

That doomed them.

[Narrator] They weren't
able to recover from the stall.

No, no, no, no, no, no, no!

[Sirens]

It was a perfect storm
of their own making.

[Narrator] nvestigators find
enoughl vidence on the voice recordinge

to conclude that fatigue
was likely one component

of the crew's poor decision making.

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.

They broke so many rules.

It makes you wonder who trained them.

[Lawrence] They weren't
following their procedures.

They missed checklists and call outs.

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.

You're not gonna believe this.

[Narrator] They are
shocked by what they find

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.

[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.

Both these guys had training issues,

and were fired because of them.

And ExecuFlight knew about it.

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 a 98 degree temperature

put in the right seat

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

So,

why did ExecuFlight hire these guys?

We start to wonder, did the company know

about these deficiencies?

If they did, did they address them?

[Silva] 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.

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.

Not much of a training manual.

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.

This was an accident waiting to happen.

[Chavez] No, no, no, no, no, no, no!

[Narrator] The NTSB concludes
that he probable cause of the crasht

was the crew's mismanagement
of their approach,

deviation from operating procedures,

and ExecuFlight's lax hiring
and training practices.

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.

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.

nd if you begin to remove thatA
tructure, you go back in times

and you lose the benefit
of all the lessons

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