Accident Details
Probable Cause and Findings
The flight crew’s decision to conduct a post-maintenance stall test in an area of icing conditions, which resulted in wing contamination that significantly decreased the airplane’s critical angle of attack. Also causal was the airplane manufacturer’s lack of training and experience requirements for the flight crew to safely conduct the stall test, which resulted in an attempted remedial action that aggravated the aerodynamic stall and led to a loss of control from which they were unable to recover. Contributing to the accident was the flight crew’s failure to follow the test conditions regarding cloud clearance, altitude limit, visual meteorological conditions, and ensuring all external surfaces were free from ice.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn February 7, 2024, about 1048 mountain standard time, a Hawker 900XP, N900VA, was destroyed when it was involved in an accident near Westwater, Utah. The PIC and SIC were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 positioning flight.
The airplane, which was owned by Vici Aviation, LLC, and operated by Clay Lacy Aviation, Inc., arrived at West Star Aviation’s facility at Grand Junction Regional Airport (GJT), Grand Junction, Colorado, on December 20, 2023, for routine maintenance. According to the maintenance facility, multiple routine inspections were completed on the airplane including a required removal of the wing leading edges and de-icing panels to inspect for cracks and signs of corrosion. The airplane was subsequently returned to service on February 6, 2024.
The flight crew planned to fly the airplane from GJT to Gig Harbor, Washington, on the day of the accident while performing a required post-maintenance stall warning and systems check en route to their destination.
At 1036:41 the SIC reported to the PIC that anti-ice was off while the airplane was on the ground before departure.
ADS-B and flight data recorder (FDR) data indicated that the airplane departed GJT at 1037 and entered a climb on a southeast heading. At 1038:45, the flight crew asked departure control for a block of altitude in the “mid-teens for about ten minutes.” Thirty-two seconds later the SIC reported again that “anti-ice is off.” At 1039:54, the PIC told the SIC “we’ll request a ah altitude once we get above in V-M-C.” The airplane made a right turn northwest as it continued to climb. During the climb, at 1042:25, the SIC asked Denver Center for a block of altitude from FL180 to FL200. Denver Center approved the altitude block and the airplane continued to climb and subsequently leveled off at 20,000 ft msl.
The FDR data showed that at 1044:00, airspeed began to decrease from 219 kts as the airplane’s pitch attitude and AOA began to increase. At 1044:41, the flight crew began to discuss the stall test. One second later the SIC is asked “so we’re taking indicateds, right” and the PIC responded “ah yeah indicated, we’re lookin’ for shaker, pusher, Ill call mark on pusher if you can’t, see it for, some reason.” The FDR showed that the autopilot was disconnected at 1045:01. At 1045:51, a sound consistent with the gear warning horn is heard, followed by an acknowledgment from the PIC and then at 1046:33 the cockpit area microphone (CAM) recorded a sound consistent with the stick shaker and the SIC reported “one nineteen.” The airplane’s pitch attitude continued to increase while simultaneously decelerating until 1046:37. While decelerating from 118 kts, at an AOA of 0.91% and 0.93% for the right and left, respectively, a pitch attitude of 15.12° for both the right and left, Stall Valve A opened. At 1046:37, the CVR CAM recorded a rattling sound that was accompanied by the sound of the stick shaker.
At 1046:47 the flight track data show the airplane began a rapid descent in a pattern resembling the shape of a corkscrew. The airplane’s flight track made multiple circular rotations before ending at 1047:44.
Figure 1: Accident airplane flight track and corkscrew descent
Please refer to the Flight Recorders section of this report for a detailed description of the FDR parametric data. PERSONNEL INFORMATIONThe PIC and SIC completed their most recent training at a commercial simulator training facility. According to one of the facility instructors, “we will do a demonstration especially for the initial class of…stick pusher on the airplane. That’s up a simulator high altitude like, I don’t know, 30,000 ft or so, and we’ll have them slow right down and we demonstrate the features of the stall protection system. So, once they get into the caution regime. We do this on autopilot, because we demonstrate that once the stick shaker goes off, your autopilot turns off. So now you’ve got to fly the airplane, but then we have them wait because if you haven’t recovered by then, you’re going to get a stick pusher, and that’s hydraulically actuated. So it’s dramatic and they just descend down, and it’s a demonstration. There’s no proficiency required for that.” An instructor at the facility reported that they do not teach full stalls.
The PIC completed his most recent recurrent training in a Hawker 800XPi simulator at the same facility in October 2023, about 9 months before the accident. He was rated satisfactory in all categories including stall prevention with flaps, without flaps, on landing, and unusual attitudes.
The SIC completed initial training in the Hawker 800XPi 4 months before the accident, and also received a satisfactory rating in every category, including the stall prevention categories referenced above. The initial training included 60 hours of ground training and 31.4 hours in the simulator; 17 hours as the pilot flying and 14.4 hours as the pilot monitoring. One simulator session dated October 24, 2023, noted that the pilot received a rating of “1” under the inflight maneuver category “Stall Prev[evention] Part/Flap,” which indicated “insufficient progress in acquiring the knowledge and skills to achieve proficiency.” The SIC also received a rating of “1” in six other areas during the same simulator session. The following day the SIC repeated the same simulator sessions and achieved a grade of “3” in each area, which is considered “proficient. The exercise has been mastered and performance is consistently repeatable.” During the checkout on October 28, 2023, the pilot received a grade of “S” (satisfactory) for all events including the “Stall Prev” areas.
The operator’s records indicated that the PIC conducted an inflight stall test once before, on December 7, 2019, and was the second-in-command on that flight. There was no record that the SIC had conducted an inflight stall test before the accident flight. AIRCRAFT INFORMATIONAccording to the type certificate data sheet (TC), the Hawker 900 XP was launched in 2006 by Raytheon Aircraft Company. The type certificate was transferred to Hawker Beechcraft Corporation on March 26, 2007, and then Beechcraft Corporation on April 12, 2013, and on October 12, 2016, to Textron Aviation, Inc., the TC holder at the time of the accident.
Before the accident, the airplane had undergone several phase inspections in addition to numerous required task inspections as a part of routine maintenance. The maintenance facility released the airplane on the day of the accident.
Stall Test Requirement
The recent maintenance that required the stall test was outlined in the structural repair manual (SRM), which required the removal of the wing leading edges every 4 years to access and remove the de-icing panels for a visual inspection of cracks and signs of corrosion (SRM task code No. 570026).
According to Section 57-41-00 of the repair manual, “WINGS LEADING EDGE AND LEADING EDGE DEVICES WING LEADING EDGE GENERAL REPAIR,”
“In accordance with the Flight Manual procedures the airplane must be test flown by a pilot familiar with the stall identification system and stall characteristics of the 750, 800, 800XP, 850XP, and 900XP series if:
(1) The leading edge assembly was removed as a whole for any reason
(2) Two or more TKS [de-icing] wing distribution panels on one side are removed or installed”
This section of the SRM also refers the operator of the Series 900XP airplane to Section V of the Pilot’s Operating Manual for the procedure and technique to complete the stall test.The manual requires that, before taking the test flight, the operator verify that the Stall Warning and Identification System is functioning properly while on the ground.
Stall Test Procedure from Pilot’s Operating Manual (POM)
The airplane’s POM contained instructions on operating limitations, system descriptions, flight planning, flight handling, and ground information.
Section V Sub-section 1 (Page 1-16) of the POM contains the required conditions and techniques to complete the stall test, separate from the SRM.
The required conditions for the stall test included an altitude above 10,000 ft above ground level, 10,000 ft above clouds and below 18,000 ft mean sea level. In addition, this check flight should only be conducted during day visual meteorological conditions with a good visual horizon, with the autopilot disengaged, an operative stall identification system, external surfaces free of ice, the ventral tank empty, and weather radar on standby.
The POM also noted that stalls should be made in “wings level” flight with thrust set and maintained throughout the approach to stall and recovery. In addition, the airplane should be trimmed to 1.4 Vs1 and airspeed should be reduced at no more than 1 kt/second. The flight crew is also required to avoid any rapid or violent control movements during the approach to the stall, particularly at airspeeds below the activation of the stick shaker.
Accident Flight Stall Test
According to the flight data recorder, the flight was flown with an empty ventral tank, and the autopilot was switched off before the flight crew began the stall test. The stall identification system was operative at the time. The flight was flown in VMC conditions about 5,000 ft above clouds and about 2,000 ft above the maximum prescribed altitude of 18,000 ft msl. The flight crew’s visual horizon at the time and weather radar status are unknown.
The crew decelerated the airplane at 1kt/second as prescribed by the published stall technique while maintaining level flight and no rapid movements were observed in the FDR data until the stall break. The flight crew’s control inputs are captured in the FDR section of this report.
Stall Characteristics
The stall test section of the POM also contained a description of the stall characteristics with a “Caution” advisory. The section noted a moderate roll was acceptable provided that the use of the aileron...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR24FA083