Good morning and welcome to the Boardroom of the National Transportation Safety Board.
I am Robert Sumwalt, and I’m honored to serve as the Chairman of the NTSB. Joining us are my colleagues on the Board: Vice Chairman Bruce Landsberg, Member Earl Weener, and Member Jennifer Homendy.
Today, we meet in open session, as required by the Government in the Sunshine Act, to consider the crash involving a Learjet 35A while approaching New Jersey’s Teterboro Airport on May 15, 2017.
Today’s board meeting is the first NTSB Board Meeting of 2019. Had it not been for the five-week partial government shutdown, this would have been the fourth Board Meeting of the year. Furthermore, the board meeting for this accident would have been last month.
In the accident we’re deliberating today, the pilots allowed the aircraft to stall, and they subsequently lost control of the aircraft as they were turning onto final approach while on a poorly flown circling approach. The airplane struck a commercial building and a parking lot and was destroyed by impact forces and a post-crash fire. Tragically, both pilots died in the crash.
On behalf of my colleagues on the Board and the entire NTSB, I would like to offer our sincerest condolences to the families and friends of the two pilots who were lost. Please understand that, as always, the purpose of our discussions is to learn from this crash to prevent similar tragedies in the future.
The accident occurred on a positioning flight operated by Trans-Pacific Air Charter, a Part 135 operator. Part 135 of the Federal Aviation Regulations governs on-demand charter operations, as well as air medical and commuter flights.
The nuance here is that because this was a positioning flight – one without revenue passengers or cargo onboard – the flight was conducted under Part 91 general operating and flight rules. However, the accident raises important questions about what can be done to improve the safety of Part 135 operations.
Part 121 of the Federal Aviation Regulations governs what most people think of when they hear “commercial aviation”— regularly scheduled air carrier flights.
If Part 135 aviation had the same tools as Part 121, we might not be here today.
One more time.
If Part 135 aviation had the same tools as Part 121, we might not be here today. This accident might never have happened.
“Improve the Safety of Part 135 Aircraft Flight Operations” is on our Most Wanted List of Transportation Safety Improvements. This accident illustrates the potential safety benefits of applying knowledge gained in Part 121 investigations, and adapting solutions already introduced in Part 121 flight, to Part 135 operations.
We realize that Parts 121 and 135 can’t do everything the same, but we believe there should be an equivalent level of safety between the two.
For example, this accident highlights the problem of procedural non-compliance. According to Trans-Pacific’s standard operating procedures (SOPs), the second-in-command, who was the pilot flying, had not yet gained the experience necessary to fly the airplane. Yet the captain of the flight disregarded company policy and allowed the second-in-command to be the pilot flying.
Both accident pilots had broken with procedures in other ways. The pilot-in-command had not obtained the weather for the accident flight leg or conducted adequate preflight planning, and the pilots did not brief the approach during the flight.
Furthermore, performance deficiencies that had been noted during the pilots’ initial training, were not being monitored by the company for recurrence. Safety programs used by Part 121 operators might have detected such deficiencies. More directly, Part 121 air carriers are required to have programs that ensure that performance deficiencies are corrected. To date, such programs are not required under Part 135.
In a former life, while serving as an airline pilot, I also was a member of a flight operational quality assurance (or FOQA) team. In that role, I looked at minor procedural deviations in non-accident flights.
Now as an NTSB Board Member, I have seen too many cases where accidents occur, including today’s case at hand, that are due, in part, to procedural noncompliance and lack of professionalism.
One thing I can tell you is that you might be born with certain aptitudes. But nobody is a born professional. It takes work and constant discipline. Professionalism is a mindset that includes hallmarks such as precise checklist usage, precise callouts and precise compliance with SOPs and regulations. Those traits were conspicuously absent on this flight.
The pilot-in-command’s use of expletives were one disconcerting symptom.
When transcribing the sounds recorded on cockpit voice recorders, the NTSB denotes expletives using the hashtag symbol. There are so many hashtags in this transcript, it reads like a social media feed—131 expletives in a half-hour. That averages to one expletive every 14 seconds. That’s just one symptom of a shocking lack of professionalism.
Another, far more problematic issue was the flight crew’s disregard for procedural compliance.
Following SOPs puts pilots in a position to succeed. They also form a strong defense against accidents. Years ago, my colleague Earl Weener led a study where he and his team analyzed over 100 airline accidents. They found that the highest ranked accident prevention strategy was for pilots to follow standard operating procedures.
Operators need to detect whether their pilots are complying with SOPs. But Part 135 operations do not have all the tools they need to ensure procedural compliance.
One such tool is Safety Management Systems (SMS) – as the FAA describes it, a formal, top-down, organization-wide approach to managing safety risk and assuring the effectiveness of safety risk controls. It includes systematic procedures, practices, and policies for the management of safety risk.
Another such tool: Flight Data Monitoring (FDM). FDM programs look at routine, non-accident data for deviations or unsafe practices, like FOQA programs in Part 121. But such programs are not currently required, and some Part 135 operators lack even the basic data-recording capabilities needed to support FDM.
The accident flight was also an example of poor Crew Resource Management (CRM). CRM done well results in effective communication and workload management, and adherence to SOPs.
However, during the accident flight, the captain had to extensively coach the second-in-command as the pilot flying while performing his responsibilities as pilot monitoring. As you’ll hear, he did neither well, and both pilots lacked situational awareness.
Here too, there is a difference between the implementation of CRM training in Part 135, versus Part 121.
There are many very good Part 135 operators, but Part 121 operators have tools that Part 135 operators do not have. The safety of Part 135 aviation can be improved.
In a moment, investigators will provide the details of the accident flight. As they present their findings, bear in mind how this flight might have been different, if lessons learned from Part 121 accidents had been applied.
Staff has pursued all avenues in proposing findings, a probable cause, and recommendations to the Board.
The order of the meeting will be that the NTSB staff will briefly present pertinent facts and analysis found in the draft report. We on the Board will then question staff. We will also propose and vote on any amendments necessary to ensure that the report as adopted truly provides the best opportunity to enhance safety.
Our public docket, available at www.ntsb.gov, contains almost 1,100 pages of additional information, including photos and postaccident interviews. Once finalized, the accident report will also be available on our website.
Now, Deputy Managing Director Paul Sledzik, if you would kindly introduce the staff.