In a final report adopted today, the National Transportation Safety Board determined that the probable cause of a corporate jet accident, was the flight crew's failure to ensure the airplane was loaded within weight and balance limits and their attempt to take off with the center of gravity well forward of the forward takeoff limit, which prevented the airplane from rotating at the intended rotation speed. The investigation revealed that neither pilot used the available weight and balance information appropriately to determine the airplane's weight and balance characteristics for the take off.
"This accident clearly shows what can happen when crucial operating steps are not adhered to," said NTSB Chairman Mark Rosenker. "When it comes to transportation safety there are no shortcuts and it is important that operators and flight crews ensure that proper procedures are followed at all times."
On February 2, 2005, a Bombardier Challenger CL-600-1A11, during takeoff, ran off the departure end of runway 6 at Teterboro Airport, Teterboro, New Jersey; through an airport perimeter fence; across a six-lane highway (where it struck a vehicle); and into a parking lot before impacting a building. The two pilots were seriously injured, as were two occupants in the vehicle. The cabin aide, eight passengers, and one person in the building received minor injuries.
The Safety Board found that contributing to the accident were Platinum Jet Management's (PJM) conduct of charter flights without proper Federal Aviation Administration (FAA) certification and its failure to ensure that all for-hire flights were conducted in accordance with Part 135 requirements. According to federal regulations, an operator must hold an appropriate air carrier certificate to operate as an air carrier and to advertise its services to the public for compensation or hire. Although PJM did not hold an appropriate certificate, the company advertised its charter services and represented itself to the public as an authorized charter operator, the Board found.
Another contributing factor was Darby Aviation's (operating certificate holder) failure to maintain operational control over Part 135 flights being conducted under its certificate by PJM, which resulted in an environment conducive to the development of systemic patterns of flight crew performance deficiencies like those observed in this accident. An example of this was the Board's findings that PJM pilots routinely improperly modified the airplane's weight and balance forms, using a variety of invalid airplane empty weights to ensure that the form indicated that the airplane was operating within its limitations.
Also contributing to the cause was the failure of the Birmingham, Alabama, FAA Flight Standards District Office to provide adequate surveillance and oversight of operations conducted under Darby's Part 135 certificate, the report states. The Board noted that although FAA personnel reviewed Darby's record, they did not ensure that PJM's airplanes were operated and maintained in accordance with Darby's company requirements or that charter trips flown by PJM were controlled by Darby.
Finally, contributing to the accident was the FAA's tacit approval of arrangements such as that between Darby and PJM. The Board stated in its findings that without clear and specific guidance on agreements between certificate holders and other entities that provide airplanes and/or flight crews for charter flights, unauthorized entities could still be performing most, if not all, of the functions of an on-demand charter operator without controls, oversight, and demonstrations of fitness imposed by a Part 135 certificate.
As a result of the investigation of this accident, recommendations to the FAA includes:
* Reviewing all charter management, lease, and other agreements between Part 135 certificate holders and other entities to identify those agreements that permit and/or enable a loss of operational control by the certificate holder and require revisions of any such arrangements
* Requiring all Part 135 certificate holders to ensure that seatbelts at all seat positions are visible and accessible to passengers before each flight
* Requiring that any cabin personnel on board Part 135 flights who could be perceived by passengers as equivalent to a qualified flight attendant receive basic FAA-approved safety training in a least the following areas (incomplete safety briefing was giving on accident flight): preflight briefing and safety checks; emergency exit operation; and emergency equipment usage. This training should be documented and recorded by the Part 135 certificate holder.
A synopsis of the Board's report, including the probable cause and recommendations, is available on the Board's website, www.ntsb.gov. The Board's full report will be available on the website in several weeks.