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General Aviation Safety
This report discusses the May 15, 2017, accident involving a Learjet 35A, N452DA, operated by Trans-Pacific Air Charter, LLC, that departed controlled flight while on a circling approach to runway 1 at Teterboro Airport, Teterboro, New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. Safety issues identified in this report include the need for flight data monitoring programs (and supporting recording devices) for 14 Code of Federal Regulations Part 135 operators; the need for safety management systems for Part 135 operators; the need for the Federal Aviation Administration (FAA) to develop and implement procedures to identify Part 135 operators whose pilots do not comply with standard operating procedures (SOP); the need for Part 135 operators to monitor pilots with performance deficiencies; inadequate FAA guidance for Part 135 crew resource management training; the need for leadership training for Part 135 PICs; and the lack of approach speed wind additive guidance in Trans-Pacific SOPs. As a result of this investigation, the National Transportation Safety Board makes three new safety recommendations to the FAA, reiterates six safety recommendations, and reclassifies one recommendation.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop guidance for Title 14 Code of Federal Regulations Part 135 operators to help them create and implement effective crew resource management training programs.
Original recommendation transmittal letter:
Open - Acceptable Response
Teterboro, NJ, United States
Departure From Controlled Flight Trans-Pacific Air Charter, LLC Learjet 35A, N452DA Teterboro, New Jersey May 15, 2017
Addressee(s) and Addressee Status:
FAA (Open - Acceptable Response)
Safety Recommendation History
We note that you are considering developing additional guidance for Part 135 operators on how to create and implement effective CRM training programs. Pending our receipt and review of your plan for developing the recommended guidance, Safety Recommendation A-19-8 is classified OPEN--ACCEPTABLE RESPONSE.
-From Daniel K. Elwell, Acting Administrator: Specific requirements for initial and recurrent Crew Resource Management (CRM) training programs for part 135 air carriers are listed in Title I 4 Code of Federal Regulations Part 135, Section 135.330, CRM Training. Each CRM training program must be approved by the FAA and tailored to the operator's flight operations and aviation environment. The FAA will consider providing additional guidance to air carriers regarding the development and implementation of CRM training programs.
On March 12, 2019, the National Transportation Safety Board (NTSB) adopted our report, Departure From Controlled Flight, Trans Pacific Air Charter, LLC, Learjet 35A, N452DA, Teterboro, New Jersey, May 15, 2017, NTSB/AAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issues: • Need for flight data monitoring programs (and supporting recording devices) for Title 14 Code of Federal Regulations Part 135 operators. • Need for safety management systems for Part 135 operators. • Need for the Federal Aviation Administration (FAA) to develop and implement procedures to identify Part 135 operators whose pilots do not comply with standard operating procedures (SOPs). • Need for Part 135 operators to monitor pilots with performance deficiencies. • Inadequate FAA guidance for Part 135 crew resource management training. • Need for leadership training for Part 135 pilots-in-command. • Lack of approach speed wind additive guidance in Trans-Pacific SOPs. Accordingly, the NTSB makes the following safety recommendations to the FAA. Additional information regarding these recommendations can be found in the noted sections of the report. • Require all Title 14 Code of Federal Regulations Part 135 operators to establish programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures during training and administer additional oversight and training to address and correct performance deficiencies. (A-19-7) (See section 2.5.3.) • Develop guidance for Title 14 Code of Federal Regulations Part 135 operators to help them create and implement effective crew resource management training programs. (A-19-8) (See section 2.6.1.) • Review operators’ Learjet 35A operations manuals to determine whether they contain manufacturer-recommended approach speed wind additives and encourage those operators without that information to add it to their operations documents. (A-19-9) (See section 2.7.2.) In addition, the NTSB reiterates the following recommendations to the FAA: • Issue an advisory circular with guidance on leadership training for upgrading captains at 14 Code of Federal Regulations Part 121, 135, and 91K operators, including methods and techniques for effective leadership; professional standards of conduct; strategies for briefing and debriefing; reinforcement and correction skills; and other knowledge, skills, and abilities that are critical for air carrier operations. (A-10-13) (See section 2.6.2.) • Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide a specific course on leadership training to their upgrading captains that is consistent with the advisory circular requested in Safety Recommendation A-10-13. (A-10-14) (See section 2.6.2.) • Require all 14 Code of Federal Regulations Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program. (A-16-34) (See section 2.4.) • After the action in Safety Recommendation A-16-34 is completed, require all 14 Code of Federal Regulations Part 135 operators to establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues. (A-16-35) (See section 2.4.) • Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs. (A-16-36) (See section 2.5.1.) • Review the Safety Assurance System and develop and implement procedures needed to identify 14 Code of Federal Regulations Part 135 operators that do not comply with standard operating procedures. (A-16-41) (See section 2.5.2.) Last, the NTSB reclassifies Safety Recommendation A-16-41 “Open—Unacceptable Response.” (See section 2.5.2.) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to email@example.com. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.
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