DeLisi: TEB Crash Spotlights Crew Performance, FDM Need

 - November 5, 2018, 11:35 AM

The National Transportation Safety Board is expected to highlight pilot performance and professionalism, along with a need for flight data monitoring, early next year as it reviews the May 15, 2017 crash of a Learjet 35A operated by Trans-Pacific Jets at New Jersey's Teterboro Airport (TEB). Both crewmembers, on a repositioning flight from Philadelphia, were killed during the accident at 3:29 p.m. EDT as they were attempting an ILS Runway 6 circle-to-land to Runway 1 approach into TEB.

While the Board has not yet made public its probable cause nor issued findings, NTSB Office of Aviation Safety director John DeLisi last week at the Bombardier Safety Standdown provided a review of some of the factors uncovered during the investigation, including that the second-in-command was the flying pilot of the accident flight. Trans-Pacific Jets had rated the second-in-command as an “SIC 0,” DeLisi said, meaning that person did not yet have the experience to control the airplane. “Yet he was flying the airplane,” he added.

DeLisi questioned the Part 91 positioning flight from the beginning, noting that for the distance from Philadelphia to Teterboro the captain had filed a flight plan for 27,000 feet. “It’s a short flight. The maximum altitude that ATC cleared him to was 4,000 feet,” he said. “What was that captain thinking? Where was his head?”

While pilots will file for more standard flight altitudes over shorter flights (the FAA preferred route from PHL to TEB has an altitude of 4,000 feet), in this case the captain showed dismay about the clearance. During the 30-minute cockpit voice recorder reading, the captain had muttered 131 expletives, DeLisi said, 115 of which involved the “F-bomb.”

“This captain would say things like: ‘What the bleep; we’re a bleeping Learjet; get us bleeping higher; we won’t bleeping make it if we got 4,000; she’s a bleeping idiot; get us someone else if she can’t do it,’” DeLisi said, substituting the expletive with bleeping.

“That’s the tone he set on what essentially was a training flight for an SIC 0 who is not yet even ready to fly the airplane,” he said, adding that at the end of the CVR readout, “the first officer is so far behind, he’s confused about what they are flying and where they are. The captain doesn’t have situational awareness…They are way behind the airplane.”

The circling approach is a common one at Teterboro where aircraft line up for Runway 6 and then circle around to Runway 1 with first a right turn out and then a left turn back toward Runway 1. The approach enables aircraft to navigate through the complex airspace in the New York region. But on the accident flight, the aircraft, N452DA, was late on the initial right turn.

According to the NTSB report, ATC cleared the flight to descend to 3,000 feet at 3:15 p.m. The New York Tracon cleared the flight for the circling approach, instructing the flight to contact TEB ATC about nine miles from the airport. However, the flight did not check in until about four miles from the airport. The tower controller cleared the aircraft to land on Runway 1 and relayed winds were 320 degrees at 16 knots, gusting to 32 knots.

According to radar track data, the flight did not start its right circling turn until it was less than a mile from the approach end of Runway 6. Typically, that turn begins at the final approach fix for Runway 6, about 3.8 nm from the approach end.

A controller observed the airplane bank hard right to the point where the wings were almost perpendicular to the ground and then level out for a second or two before the left wing dropped, showing the entire top of the airplane, NTSB said.

Toward the end of the cockpit voice recording, the captain tells the first officer to “watch your airspeed” and the first officer responds “your flight controls.” DeLisi noted, “He gives up the airplane. They are on final approach cleared to land, and they haven’t begun to make the circle maneuver.”

At this time the enhanced ground proximity warning system begins to sound alerts and the SIC again asked to hand over the controls. This time the captain acknowledges it, but the Learjet stalls shortly afterward, crashing into a building and a parking lot.

Subsequent investigation revealed histories of failed checkrides and firings from former employers for the crew, DeLisi said.

The accident also spotlights a lack of requirement for flight data monitoring or safety management systems for Part 135 operators, he said. It also shows a need for Part 135 operators to monitor pilots for performance issues, “but in the absence of flight data monitoring, you don’t know how the airplane is being flown,” DeLisi added.

He also brought up one other issue to the Safety Standdown audience: “In the era of a pilot shortage, if you do come across a crewmember who presents themselves well… but that may have had some deficiencies previously...set up a performance monitoring program.” Such a program, he said, should include remedial coaching.

The NTSB had expected to address this accident next month but has since pushed off its Board meeting until early next year, likely in February.