NTSB · Safety Recommendation
Safety Recommendation A-16-013
Recommendation
TO THE GENERAL AVIATION MANUFACTURERS ASSOCIATION: Work with the Federal Aviation Administration to develop a system that can automatically alert pilots when the ice protection systems should be activated on turbofan airplanes that require a type rating and are certified for single-pilot operations and flight in icing conditions.
Safety Issue and Context
On December 8, 2014, about 1041 eastern standard time, an Embraer EMB-500 airplane (marketed as the Phenom 100), N100EQ, registered to and operated by Sage Aviation LLC, crashed while on approach to runway 14 at Montgomery County Airpark (GAI), Gaithersburg, Maryland. The airplane impacted three houses and the ground about 3/4 mile from the approach end of the runway. A postcrash fire involving the airplane and one of the three houses, which contained three occupants, ensued. The pilot, the two passengers, and the three people in the house died as a result of the accident. The airplane was destroyed by impact forces and postcrash fire.
The flight was operating on an instrument flight rules flight plan under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed at the time of the accident.
Data from the airplane’s cockpit voice and data recorder (CVDR) indicated that the takeoff about 0945 from Horace Williams Airport, Chapel Hill, North Carolina, and the cruise portion of the flight were uneventful.1 CVDR data showed that about 15 minutes after takeoff, the passenger in the right cockpit seat made a statement that the airplane was “in the clouds.” A few seconds later, the airplane’s engine anti-ice system and the wing and horizontal stabilizer deice system were manually activated for about 2 minutes before they were manually turned off.
About 6 minutes later, a recording from the automated weather observing system (AWOS) at GAI began transmitting over the pilot’s audio channel, containing sufficient information to indicate that conditions were conducive to icing during the approach to GAI.2 The CVDR recorded no activity or faults during the rest of the flight for either ice protection system, indicating that the pilot did not turn the systems back on.
The NTSB determines that the probable cause of this accident was the pilot’s conduct of an approach in structural icing conditions without turning on the airplane’s wing and horizontal stabilizer deice system, leading to ice accumulation on those surfaces, and without using the appropriate landing performance speeds for the weather conditions and airplane weight, as indicated in the airplane’s standard operating procedures, which together resulted in an aerodynamic stall at an altitude at which a recovery was not possible.
Response History
July 21, 2021 · NTSB Correspondence · General Aviation Manufacturers Association
We have not received any information from GAMA regarding this recommendation since your September 20, 2016, letter, which said that GAMA was organizing a workshop on icing, aircraft aerodynamics, and loss of control, among other important general aviation safety issues. You further reported that information from this workshop would be forwarded to ASTM International’s F44 Committee on General Aviation Aircraft, which would develop standards for airplanes certified to fly into icing conditions. Pending our review of the developed standards and completion of the recommended actions, Safety Recommendation A-16-13 was classified OPEN-- ACCEPTABLE RESPONSE on October 31, 2016.
Copies of previous correspondence are enclosed.
We normally expect actions to address our recommendations to be completed within 3 to 5 years. It has now been over 5 years since this recommendation was issued, and we have not received any additional information regarding your actions to implement it. We would appreciate receiving a response from you within 90 days regarding actions that you have completed or planned to address this recommendation. Please update us at ExecutiveSecretariat@ntsb.gov on your progress toward implementing this recommendation, and do not submit both an electronic and a hard copy of the same response.
Thank you in advance for your prompt response and for your commitment to aviation safety.
October 31, 2016 · NTSB Correspondence · General Aviation Manufacturers Association
We note that you are organizing a workshop that will be held October 25¬¬¬–27, 2016, in Orlando, Florida, which will address icing, aircraft aerodynamics, and loss of control, among other important general aviation safety issues. The planned output of the workshop will be a comprehensive set of standards that address all types of general aviation airplanes and that will be forwarded to ASTM International’s F44 Committee on General Aviation Aircraft. The committee will then develop standards for airplanes certified to fly into icing conditions.
Earlier this year, the FAA published a notice of proposed rulemaking (NPRM) to revise Title 14 Code of Federal Regulations