The scene of the crash at Grand Bahama shipyard.
EXCLUSIVE
By RASHAD ROLLE
Tribune Staff Reporter
rrolle@tribunemedia.net
THE pilots of the Learjet that crashed and killed all nine on board in Grand Bahama last year disabled the plane’s “terrain awareness warning system” when it warned them they were flying too low and deliberately failed to adhere to standard procedures, according to the official aircraft accident report of the incident.
One of the pilots said “ah, shut up” before disabling the terrain awareness warning system (TAWS) when it was advising them that they were “too low” and needed to “pull up,” according to an analysis of the cockpit voice recorder (CVC).
The plane was carrying Dr Myles Munroe, his wife, Ruth, and other members of Bahamas Faith Ministries International to a global leadership conference in Grand Bahama when it crashed into a junkyard crane in bad weather on November 9. According to the report one of the pilots exclaimed “climb, climb, climb” just before impact with the crane.
The picture painted by the report – by the Air Accident Investigation and Prevention Unit (AAIPU) of the Civil Aviation Department – depicts pilots who, despite their experience and clean performance histories, made a series of inexplicable decisions that ultimately doomed the flight.
The accident report, a copy of which has been obtained by The Tribune, said the crew flew below the minimum required altitude and that the pilots withheld this information from Air Traffic Control (ATC) while trying to navigate through poor visibility.
Investigators said the crew lacked crew resources management (CRM), a set of training procedures used in environments where human error could have fatal consequences.
The crew’s landing attempts were also “unstabilised” during both their first and second approaches, meaning that they exceeded the average rate of descent for planes.
“Notwithstanding the unstabilised approach flown in this case,” investigators said, “a properly trained and experienced pilot, who is vigilant and alert, should have been able to land the airplane successfully. Both pilots were trained properly and had sufficient
experience to prepare them to complete a safe landing following an unstabilised approach.”
Investigators said that a “strong motivator and psychological factor” acting on the crew was the “presence of and need of VIPs on board to get to Freeport that evening.”
The release of the accident report comes as the family of Diego DeSantiago, an American citizen, has said it will sue Diplomat Aviation, the company under which the Learjet was registered, for damages.
Investigators said “the accident was not survivable for any of the nine people on board the flight because of severe impact forces and destruction of the airplane during the crash sequence.”
Toxicology tests performed on the pilots turned up negative results for “amphetamines, opiates, marijuana, cocaine, phencyclidine, benzodiazepines, barbiturates, antidepressants and antihistamines.”
Both pilots were licenced and certified by the US Federal Aviation Administration (FAA) and in possession of valid first class medical certificates as required by regulations. They held a medical certificate that said they “must wear corrective lens.”
As of November, the captain, Stanley Thurston, 62, reported over 13,500 hours in the air. His co-pilot, Frankan Cooper, 35, reported pilot hours of 1,020.
FAA records of both men indicated that no prior accidents, violations or enforcement actions ever took place against either man.
However, the report said: “From training records reviewed, no evidence of crew resource management (CRM) could be established as having been completed during the latest recurrent retraining.”
The report says: “It became apparent during the investigation that the crew intentionally went well below the published glideslope during their approach and withheld this information from ATC. There is evidence that the lack of CRM contributed to this accident.
“There were no standard cockpit management procedures being followed during the last 30 minutes of the flight. The (pilot in charge) appeared more passive and the (second in charge) was more commanding in issuing instructions of what was going on at the time. There is strong evidence that came from the CVR recording that indicate that one of the pilots wilfully disabled the terrain awareness warning system (TAWS) while it was alerting them to the presence of ‘terrain’ and advising them that they were ‘too low’ and to ‘pull up.’
“Despite advising ATC of their altitude as 2,000 feet (on approach), the aircraft was actually at 1,000 feet and descending looking for the runway visually and not on the glideslope approach as approved by ATC. Additionally, the aircraft never entered or held at the published holding position or altitude as they advised ATC they were doing.
“The aircraft also never maintained the authorised altitude as they made the approach from the area of the holding position toward the airport. Radar data from Miami Centre supports this assertion. CVR recording also supports this assertion during the final minutes of the flight after departing the area of the holding position.
“As Freeport International Airport does not have radar in which to detect and verify aircraft position, there was no way for controllers to know an aircraft was not in fact at the position or altitude they reported.”
“The descent into Freeport area and the approach for landing was not flown on the specified altitude required for this approach on the first or second attempt for landing,” the report said.
“The crew continued descent below the minimum required altitude despite warnings from the TAWS system that they were below the glide slope.”
The report said that Diplomat Aviation Ltd failed to turn over to investigators the records of the pilots in time for the report’s publication, despite claiming to have them.
The report said the Grand Bahama Shipyard sustained minimum damage to its crane and that surrounding areas also reported minimal damage.
However, a generator unit and equipment in the adjacent recycling plant of City Services Ltd received extensive damage. The damage, according to management personnel of the organisation, exceeds $1m.
Comments
proudloudandfnm 9 years, 1 month ago
Seems the pilots made nothing but irresponsible decisions....
B_I_D___ 9 years, 1 month ago
Oh that's NOT good...
J360 9 years, 1 month ago
Investigators said that a “strong motivator and psychological factor” acting on the crew was the “presence of and need of VIPs on board to get to Freeport that evening.”
But what exactly does this mean? Were they under pressure to get the VIP's to Freeport that evening at all costs? Did this unwittingly cause them to make improper decisions?
Exactly what caused the investigators to come to this conclusion (was something overheard)?
So many questions, but I guess we can never really know... My prayers go out to the families who still have to deal with being reminded of this tragedy...
TalRussell 9 years, 1 month ago
I can only hope the Comrades who accused me of being insensitive way back when I said the investigators cannot ignore the dominance of the on-board "you can do it" attitude, having played a major role as to why the pilots did not turn the plane around to head back to Nassau - will also read this report. Just maybe 9 lives lost because of one man's strong influence over a flight crew's repeated bad piloting judgement decisions?
bigbadbob 9 years, 1 month ago
it has been said the pilot complaind there were to much luggage and people there for only put 165 ga of fuel . there was no sigificant fireball or flames when it hit , it was basicly running on empty.
TalRussell 9 years, 1 month ago
Comrades since the 1930's the following phase has been reproduced many times on posters and plaques. Many a pilot still visibly post it in their cockpits. Reproduced almost always with the attribution of 'anonymous.'
"Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect".
B_I_D___ 9 years, 1 month ago
Amen to that...hence why more often than not, it is pilot error not mechanical. Another one is, there are old pilots and bold pilots, but not many old bold pilots. The mechanical problems lead you to the NEXT phrase..."Aviation is hours and hours of boredom punctuated by moments of sheer terror!!"
paul_vincent_zecchino 9 years, 1 month ago
Well said, sir.
TalRussell 9 years, 1 month ago
Comrade the three top causes for plane crashes are #1: Pilot Error (Poor Judgment/Lack Training #2: Pilot Error (weather related) #3: Pilot Error (mechanical related)
#4 Other Human Error (Hardly Registers)
JB357 9 years, 1 month ago
I believe they were under pressure to deliver because of the VIP's on board. I think it shows that safety must come first regardless of who is on board and pilots must be stern in making a safety call. We saw it in the Aaliyah crash as well. My prayers are with the families of the victims.
TalRussell 9 years, 1 month ago
Comrade my friend flew fugitive criminal Robert Vesco's Boeing 707 private airliner jet and I can tell you stores about how Robert would do anything , including flying through dangerous weather conditions, all to avoid ever entering US friendly airspace. He was terrified of being forced to land by US or US friendly fighter jets. Let's put it this way, there was always a briefcase stashed with US $100 bills to pay off airport officials - cuz the only way Robert's jet could land was to pay cash for landing fees, fuel, flight services and of course the many corrupt airport and government officials along the way. Oh yes, also a number of well-known Bahamalnd's politicians and government officials included.
Well_mudda_take_sic 9 years, 1 month ago
It is abundantly clear that the aircraft that crashed and its flight crew (pilot and co-pilot) served the business and other interests of BFM and, therefore, for all legal intents and purposes effectively "belonged" to BFM. Accordingly, any life insurance benefits received by Dr. Munroe's children and or BFM should be apportioned in a fair and equitable manner among all the passengers that perished as a result of the errors attributable to the flight crew.
Publius 9 years, 1 month ago
Woa
DEDDIE 9 years, 1 month ago
Limited Liability Company and Corporation are separate legal entities from their owners. The latest Supreme Court ruling actually impute religious belief on such entities. BFM is not culpable.
Reality_Check 9 years, 1 month ago
If the jet was owned by a U.S. LLC and Dr. Munroe or another official of BFM "checked the box" for U.S. income tax purposes whereby the corporate veil is effectively lifted, then everything (all liabilities) simply flow through to the foreign (non-U.S.) beneficial owner of the U.S. LLC.
Publius 9 years, 1 month ago
Now just get the CVR transcripts for the record. This information still should be obtained by the media. The NTSB has already essentially told us what happened in the cockpit on this ill-fated flight.
Publius 9 years, 1 month ago
Forgot to say they should get the FDR information as well. But since I don't expect our media to do any of this, nor do I expect them to publish information they may have or could obtain that might paint Mr. Munroe in a negative light, I imagine the public will have to await the CVR and FDR records as part of court proceedings for the DeSantiago family lawsuit.
TalRussell 9 years, 1 month ago
Comrade Publius, if the media won't even disclose the name of the quarter million dollars former BEC board member thief - don't be holding your breath. Acting like their printer ink wells run out ink, preventing their publishing the thief's name? Why not one picture Carnival 2015's outhouse toilets, or at least the costs budget?
Publius 9 years, 1 month ago
While we don't yet have the CVR transcripts, we can reasonably assume from the NTSB's findings about cockpit management on this flight that the pilot and co-pilot were at odds and/or not working together as they ought in the cockpit. With the pilot "going passive" and the first officer doing everything, it may have been that the pilot knew that what was being done was not right or safe, but was afraid or unwilling to challenge his pastor, and therefore instead of doing what was necessary as the Captain he backed down and allowed the cowboy first officer to take all of them to what ended up being their regrettable deaths. Think about it. The NTSB does not know the pilots and passengers personally and there were no survivors to interview. For them to make the statement they did about the need for the VIPs to land in Freeport that evening, something had to have been said in that cockpit by either Munroe or the pilots to cause them to come to such a conclusion. How else could they possibly know whether the VIPs on board were actually fine with returning to Nassau or landing elsewhere since it may have been safer to do so? No investigator would be able to magically know what the VIP wanted and preferred from what he did not. Their conclusion suggests that Munroe insisted at some stage that they attempt to land instead of perhaps returning to Nassau or landing somewhere else, or that he made clear his desire prior to the start of the flight, which the pilots echoed during flight. Of course it is still the pilots' responsibility to do what is right and necessary no matter what a passenger says or wants, but based on what the NTSB said, I'm willing to bet the CVR transcripts show the "don't challenge the man of God" syndrome happening with this entire flight.
ted4bz 9 years, 1 month ago
Any Captain that is not in charge of his ship is no Captain in the first place. I said all that already and this says it all without calling names...
ted4bz 9 years, 1 month ago
Turing off the Ground Proximity Warning System means absolutely nothing and have nothing to do with the crash of this aircraft. The aircraft did not hit the ground and most certainly the GPWS could not warn the pilot that it was approaching an object erected 300 feet in its path (in the clouds and fog). There are many warning sounds in the aircraft and since the aircraft is also equip with an altimeter which when correctly set can do the job when TAWS is absent. Since the terrain was not the challenge but rather the weather condition and locating of the runway for a proper approach then turning off TAWS from being a nuance made sense (no harm done here). While this report is good pastime it is certainly not one to raise eyebrows.
TalRussell 9 years, 1 month ago
Comrade Ted4bz conclusion, you've either never piloted, or you are a piss poor one - cuz the Lear jet's GPWS is designed to do exactly what turning it off - prevented it from doing and that was to alert the two pilots that their aircraft was in immediate danger of flying into an obstacle and in this case a construction crane and within mere seconds. There is no mistaken how a number of poor piloting decisions were being made in that cockpit, which would eventually result in the killing of all 9 aboard., including the two pilots. There is no excusing their poor judgment calls and I hope the courts will make someone pay their surving family members and pay them dearly where it will hurt the most - their pockets/bank accounts.
SP 9 years, 1 month ago
Totally avoidable, unfortunate accident....Nuff said.
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