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Safety Recommendation Details

Safety Recommendation A-19-009
Details
Synopsis: 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.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: 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.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Teterboro, NJ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CEN17MA183
Accident Reports: Departure From Controlled Flight Trans-Pacific Air Charter, LLC Learjet 35A, N452DA Teterboro, New Jersey May 15, 2017
Report #: AAR-19-02
Accident Date: 5/15/2017
Issue Date: 3/28/2019
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/11/2019
Response: We note that you plan to review operators’ Learjet 35A operations manuals to determine if the manufacturer-recommended approach speed wind additives are included. We also note that you are evaluating the feasibility of revising FAA Order 8900.1, “Flight Standards Information Management System,” to direct principal operations inspectors to encourage any operators who do not have this information in their operations manuals to include it. Pending our review of your assessment and the revised order, Safety Recommendation A-19-9 is classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/18/2019
Response: -From Daniel K. Elwell, Acting Administrator: We will conduct a review of the operators' Learjet 35A operations manuals to determine if they include manufacturer-recommended approach speed wind additives. We will also evaluate the feasibility of a revision to FAA Order 8900.1 Flight Standards Information Management System to direct that principal operations inspectors encourage those operators without that in fom1ation to add it to their operations manuals. I will keep the Board informed of our progress on these safety recommendations and anticipate providing an update by July 2020.

From: NTSB
To: FAA
Date: 3/28/2019
Response: 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 correspondence@ntsb.gov. 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.