Challenger crash sheds light on control issues
While the NTSB ruled that the chartered Challenger 600 that overran a runway at Teterboro Airport (TEB) on Feb. 2, 2005, was loaded improperly, the accident also shone a spotlight on the murky issue of operational control of such flights.
The NTSB said that the FAA contributed to the accident by failing to provide surveillance and oversight of operations conducted under another company’s Part 135 certificate and by giving tacit approval to such arrangements between the charter provider and the actual certificate holder.
Fort Lauderdale, Fla.-based Platinum Jet Management was operating the Challenger 600-1A under the auspices of a charter management agreement with Darby Aviation of Muscle Shoals, Ala., when the airplane ran off the departure end of Runway 6 at TEB at a groundspeed of about 110 knots.
It went through an airport perimeter fence, across a six-lane highway–where it struck a vehicle–and into a parking lot before penetrating the side of a building and coming to rest. 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.
Bill English, the NTSB investigator-in-charge, said that in addition to attempting a takeoff with the c.g. well forward of the forward takeoff limit (which prevented the airplane from rotating at the intended rotation speed), the aircraft was 100 pounds overweight.
Steve Demko of the Board’s operations division said neither pilot did weight-and-balance calculations and they “did not say why they didn’t.”
Crew Experience Questioned
The pilots’ failure to ensure that the airplane’s weight and center of gravity were within approved takeoff limits was symptomatic of poor airmanship and a broader pattern of deficiencies in their crew resource management skills, specifically in the areas of leadership, workload management, communications/briefings and crew coordination, the Safety Board said.
The NTSB found that Platinum Jet pilots routinely improperly modified the airplane’s weight-and-balance forms, using invalid airplane empty weights to ensure that the form indicated the airplane was operating within its limitations.
Investigators added that the pitch trim setting the pilots selected is further evidence that they did not consider the airplane’s center of gravity during preflight preparations, but the captain’s decision to initiate the rejected takeoff (RTO) was reasonable even though the airplane had already reached a higher-than-normal RTO speed.
At an October 31 public hearing on the crash, NTSB chairman Mark Rosenker said, “I am genuinely disturbed about what we are learning here today.”
The captain stated he had normal acceleration of the airplane and when the first officer called the rotation speed, he could move the column only about one inch aft. TEB tower controllers observed that the airplane speed appeared normal and noticed the nosewheel did not lift off the ground. The controllers indicated the airplane was still on the runway beyond the point where most airplanes become airborne.
According to the first officer, the airspeed was accelerating through 165 knots when the captain called “abort.” The first officer stated the nose of the airplane never lifted off the ground. Simulator tests indicated that most line pilots attempting to abort a takeoff five seconds after reaching the expected rotation speed and well above that rotation speed would not have been able to stop the accident airplane in time to avoid running off the end of the 6,013-foot runway.
The NTSB also cited the pilots’ qualifications, or lack thereof, as a contributing factor. Although the captain claimed to have six type ratings, the NTSB said his experience was “difficult” to determine. He had been terminated by two previous employers, had two type-rating failures and did not meet the currency requirements for Part 135 operations.
The Board questioned the validity of his reported flight times and previous training, noting that he held the certificates required to act as PIC of CL-600 flights under Part 91 but had not yet received the training to operate Part 135 flights for Darby Aviation.
The first officer was a citizen of Venezuela and had received only 22 of the 31 hours of ground training required by Darby’s operations specifications to perform second-in-command duties on a CL-600 being operated under Part 135. Additionally, his FAA medical certificate had expired for the purposes of commercial operations.
Also contributing to the accident, the NTSB said, was Platinum Jet Management’s conduct of charter flights using its own pilots and airplanes without proper FAA certification and its failure to ensure that all for-hire flights were conducted in accordance with Part 135 requirements; Darby Aviation’s failure to maintain operational control over Part 135 flights being conducted under its certificate by Platinum Jet Management, which resulted in an environment conducive to the development of systemic patterns of flight crew performance deficiencies like those observed in the accident; the failure of the Birmingham, Ala., FSDO to provide adequate surveillance and oversight of operations conducted under Darby’s Part 135 certificate; and the FAA’s tacit approval of arrangements such as that between Darby and Platinum Jet Management.
The NTSB said that Darby Aviation failed to maintain operational control over on-demand charter flights conducted by Platinum Jet Management under Darby’s Part 135 certificate, as required by the FARs. Because neither Darby nor Platinum Jet was rigorous about enforcing the federal requirement for operational control, Platinum Jet pilots operated in an environment in which pilot errors and/or omissions during preflight preparation were less likely to be detected before departure.
The FAA’s inadequate oversight of the Part 135 charter management agreement between Platinum Jet and Darby permitted management failures and a lack of operational control to exist, according to the Safety Board.
The Safety Board said that Darby Aviation’s Birmingham, Ala. FSDO-based principal inspectors should have requested assistance from a FSDO more conveniently located to Platinum Jet’s Fort Lauderdale-based operations to ensure proper oversight of the operations conducted by Platinum Jet under Darby’s certificate.
“The FAA failed to perform adequate charter operator surveillance and therefore did not recognize that PJM operated as a de facto 14 CFR Part 135 carrier, despite the lack of necessary personnel; policies; procedures; and FAA approvals, certification and oversight that would normally be associated with such operations,” the NTSB determined.
Without clear and specific guidance on agreements between certificate holders and other entities that provide airplanes and/or flight crews for charter flights, the Board continued, unauthorized entities could still be performing most, if not all, of the functions of an on-demand charter operator without the controls, oversight and demonstration of fitness imposed by a Part 135 certificate.
The Board also found that the cabin aide’s training did not adequately prepare her to perform the duties with which she was tasked, including opening the main cabin door during emergencies.