Human Factors: Inside 3 Business Aircraft Accidents

With very rare exception, the human at the controls is a key factor in every aviation mishap. All-too-common elements such as fatigue, job pressures, “get-there-itis” and task saturation conspire to quickly turn challenging situations into fatal accidents, as seen in the following reports from the NTSB and firsthand insights from qualified industry professionals.

A Hawker 900XP departed controlled flight over Westwater, UT, during post-maintenance stall testing – 2 fatalities.

NTSB Probable Cause: “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 [at which the wing stalls]. Also causal was the airplane manufacturer’s lack of training and experience requirements for the flight crew to safely conduct the stall test…”

Such post-maintenance tests are required in Hawker 125-series jets following removal of the leading edge TKS deicing panels from the wing to facilitate corrosion inspections, as handling qualities may be negatively affected after reinstallation.

Andrew Day, vice chair of the NBAA Safety Committee and chief operating officer for WYVERN, noted the accident flight crew opted to conduct the required test as they repositioned the aircraft to Seattle, WA. “They may have felt this was just a routine check to complete,” he said. “And the current flight manual implies that pilots qualified for normal operations are also qualified to conduct those stall tests.”

However, the potential dangers from such tests are generally known throughout that pilot community. Day recalled his first experience with the issue years ago as CEO of a Part 135 charter operation. “One of my favorite captains refused to perform the post-maintenance check,” he said. “He told me, ‘I love my job, but I’m not trained and qualified to do this. It is vastly unsafe.’ And I realized he was absolutely right to do so.”

That led Day to pursue his type-rating in the series so that he would be available to perform those checks, relieving line pilots of that task. “We had what I would consider a pretty robust safety system in place,” he added. “I thought we were doing all the right things, but here was a situation that exposed our operation and our pilots to real danger, despite being in full compliance with the regs.”

Those risks were reaffirmed by a second accident over Michigan in October 2025, which claimed the lives of the three persons onboard. The NTSB noted the pilots of the Hawker 800XP had been provided with a list of experienced pilots to perform the test, but opted to conduct the check themselves “after being unable to coordinate the stall test flight with a test pilot.”

These accidents led the NTSB to call on the FAA to establish mandatory specialized, high-experience pilot training for post-maintenance stall tests. They also urged the manufacturer to revise flight manuals to address the potential for severe and unexpected stall behaviors.

In another urgent safety recommendation to NBAA, the Board asked the association to “inform its members about the circumstances of these accidents and the safety issues identified.” Day noted those actions have already yielded results.

“We’ve seen many operators say they won’t approach their line staff [to perform post-maintenance stall testing], but rather find specially qualified crews,” he said. “They want to do it right, even if it means a canceled trip. But the truth is [these flights are] probably still happening every day, despite the best intentions.”

A Mitsubishi MU-2B-40 Solitaire crashed near Copake, NY, while maneuvering following a missed approach – 6 fatalities.

From the NTSB preliminary report: “At 1157:52, the pilot advised the controller that he was on a missed approach and when queried by the controller about his intentions, he responded that he would take vectors for another approach … At 1202:40, the controller instructed the pilot to cross PUCBY at 4,000 ft msl and cleared him for the RNAV (GPS) Runway 3 approach at 1B1, which the pilot acknowledged. About 1 minute later, the controller advised the pilot of a low altitude alert, and to check his altitude immediately, with no response from the pilot.”

The NTSB further noted that, based on recorded security camera video, a low overcast cloud layer was present at the time of the accident. That likely added more stress to an already challenging situation, said NBAA Safety Committee member Norman “DQ” Dequier, vice president of flight operations at Aviation Performance Solutions.

“These are really complex scenarios,” he said. “There’s a lot of turning, altitude changes, power and airspeed changes going on. That’s an awful lot for a single pilot to keep up with in that environment and it becomes a lot more difficult for that single pilot to be doing all the actions required, particularly with the performance of modern aircraft.”

Modern avionics and autopilots “can be a fantastic second pilot,” Dequier continued. “But things can come at you so fast and you can very quickly become task saturated. If you’re pushing buttons every 15 seconds, it’s taking up so much of your time that it’s difficult to keep up with everything else.”

Dequier recommended pilots look at this situation as a reminder of the importance of their authority as pilot-in-command. “We do have latitude as pilots to build in more time,” he said. “Tell ATC you’re reducing power and climbing out at a shallower angle to minimize the possibility of disorientation, especially when in a turn, or that you need a delaying vector. Advise them you need a longer approach corridor to help you get caught up again.

“It’s difficult sometimes to make that decision when you’re already feeling like everything is coming at you fast,” he added. “We’re so used to doing things quickly. We even pride ourselves on our ability to keep up with it all. I think sometimes we don’t think enough about, ‘how can I slow this down?’”

An Epic E1000 turboprop single impacted terrain while approaching Steamboat Springs Airport (SBS) shortly after midnight – 4 fatalities.

From the NTSB preliminary report: “The waypoints in the data were consistent with the RNAV Z RWY 32 approach. The minimum descent altitude for the approach is 9,100 ft. msl. The last recorded altitude for the airplane was 8,221 ft. msl … The RNAV Z 32 approach plate lists that the approach, both the circling and straight-in to Runway 32, is not authorized at night. Additionally, the approach plate lists “Visual Segment – Obstacles.”

This accident occurred approximately six hours after the aircraft departed Nashville, with a stop in Kansas City along the way. “The chain of events that led to this outcome likely began before the airplane ever left the ground,” said Gregory Feith, former senior NTSB air safety investigator. “You must consider preflight planning and the pilot’s experience.

“And, why Steamboat?” he continued. “It’s a small airport with a 4,400-foot runway. If you’re landing at midnight, why not divert to [Yampa Valley Regional Airport in] Hayden? It’s a 20-minute drive. Was fatigue a factor? They may have wanted to get there and to be as close as possible.”

Attention on this accident has focused on the approach to Runway 32, which is not approved at night. Feith noted the aircraft’s Garmin G1000 NXi panel would have alerted the pilot to the non-certified approach, but would still have provided guidance in an advisory capacity.

“It doesn’t give you vertical guidance,” he added, “but it will project a three-degree flight path to the runway in, again, an advisory-only mode. And it could draw that line right through a mountain.”

[NOTE: Garmin has since issued Service Alert 26027 addressing possible risks involving use of advisory vertical guidance (+V) on non-precision approaches on its avionics. It noted, “Misinterpretation of advisory vertical guidance and/or failure to monitor barometric altitude while flying a non-precision instrument approach may result in an unintentional descent below published altitude restrictions including the Minimum Descent Altitude (MDA).”]

While the NTSB’s probable cause findings were not released and available at the time this article was written, Feith said the accident highlights the risks of single-pilot IFR flying. “It’s really the hardest flying out there,” he added. “You are the navigator, you’re the communicator, you’re the operator of the aircraft. Your workload goes right through the ceiling.

“In this case, the pilot had his son and two others back there,” Feith continued. “As pilots, we do not like to fail. We have a highly capable, $4.5 million airplane to use to travel from Point A to B. We don’t like going to Point C. And so now you have that self-induced pressure to accomplish the mission, which can push pilots to rationalize, justify or even basically ignore good aeronautical decision-making.”