Premium on Safety - Issue 49, 2023 - 19

LESSONS LEARNED
coming down; its airspeed was 113 knots.
One-tenth of a second after the captain said,
" Okay, level off, guy, " the CVR began recording
the sound of the stick shaker. Five seconds
later, the ground proximity warning system
called, " Pull up. " The initial sounds of impact
came two seconds after that. The Hawker
stalled into a four-unit apartment building,
destroying it and two cars. Somehow no one
on the ground was hurt.
essential points. The approach checklist was
never run. Configuration changes were not
called out as required for step-down altitudes
or position fixes during the approach.
The NTSB's review found that this
flight crew had violated company
SOPs on every preceding leg
of the trip, from failing to file
alternate airports when required
to using generic rather than
actual passenger and baggage
weights in computing weight
and balance.
The NTSB's catalogue of the crew's procedural
errors is extensive. Their IFR flight plan listed

Premium on Safety - Issue 49, 2023

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