NTSB: Pilot Error Caused 2014 Phenom Crash


The pilot of an Embraer Phenom failed to turn on crucial de-icing equipment during an approach to the airport in Gaithersburg, Maryland, on December 8, 2014, causing a deadly crash, the NTSB said in its probable-cause hearing today. All three people on the jet and three on the ground were killed. “Pilots must rely on checklists and procedures because relying only on memory can have deadly results,” said NTSB Chairman Christopher Hart. “The pilot’s failure to turn on the de-icing system in an icing situation proved to be disastrous.” By not taking possible icing into consideration, the pilot set approach and landing speeds that were too slow for conditions, leading to an aerodynamic stall at an altitude at which a recovery was not possible, the board said. The airplane crashed less than a mile from the runway.

The board recommended to the FAA and GAMA that they develop a system that would automatically alert pilots when ice-protection systems should be turned on in certain airplanes. “Because pilots are human and therefore fallible,” said Hart, “this crash is a reminder that automated alerts to pilots can, and do, save lives.” The NTSB also recommended to NBAA that it develop enhanced pilot-training guidelines for flying in winter weather conditions, including the use of ice protection and adherence to checklists. Hart also noted that Embraer had installed a cockpit voice and data recorder on the jet, although it was not required to do so, and that data “enabled a richer understanding of what occurred.” A report from the NTSB board meeting is posted online; the board’s final report on the accident will be posted in a few weeks.