NTSB Renews Call for Mandatory FDM, SMS for Part 135

 - March 13, 2019, 12:16 PM

The National Transportation Safety Board (NTSB) yesterday renewed its call for the FAA to mandate flight data monitoring and to implement measures to improve training and safety management on all Part 135 operations. In all, the NTSB made three new and reissued six previous recommendations as a result of its findings on the May 15, 2017 crash of a Learjet 35A (N452DA) near Teterboro Airport in New Jersey (TEB). Both the pilot-in-command (PIC) and second-in-command (SIC) were killed on the Part 91 positioning flight after they lost control of the aircraft during a circling approach to TEB’s Runway 1 and crashed into a nearby commercial building and parking lot.

During its March 12 board meeting in Washington, the NTSB agreed that the probable cause of the accident was “the PIC’s attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.” The Safety Board cited as a contributing factor the decision of the PIC to allow an unapproved SIC to act as the pilot flying, the PIC’s inadequate and incomplete preflight planning, and the flight crew’s lack of an approach briefing.

The NTSB additionally pointed to operator Trans-Pacific’s lack of safety programs, which the agency said, “would have enabled the company to identify and correct patterns of poor performance and procedural noncompliance.” Further faulted were ineffective FAA safety assurance system procedures, which failed to identify company deficiencies, the Safety Board added.

The fatal crash occurred on the crew’s third and final scheduled flight of that day. Earlier, the crew had flown from TEB to Laurence G. Hanscom Field (BED) in Bedford, Massachusetts, and then from BED to Philadelphia International Airport (PHL), before the return to TEB.

While the PIC checked the weather at the beginning of the day, he did not check the weather again before that last leg from PHL to TEB, where the winds were reported as strong and gusty at the time of the accident. Company policy stipulates that pilots check weather within three hours of departure. In addition, the crew’s flight plan for the 28-minute PHL to TEB leg called for a cruising altitude of 27,000 ft. NTSB noted that the flight plan's time and altitude entries “were incompatible with each other, [suggesting] that the crew devoted little attention to preflight planning.” Further, since the crew had limited time during the flight to brief the approach, no such approach briefing was conducted, despite company policy.

Cockpit voice recorder data indicated that the SIC was the pilot flying (PF) on that last leg, even though the SIC did not meet the company’s minimum level of experience for such flight. The PIC regularly coached the SIC, coaching that the NTSB believes “likely distracted the PIC from his duties as PIC and pilot monitoring, such as executing checklists and entering approach waypoints into the flight management system.”

The NTSB found that “collectively, procedural deviations and errors resulted in the flight crew’s lack of situational awareness throughout the flight and approach to TEB.” The airplane’s navigation equipment had not been properly set for the instrument approach clearance that the flight crew received, but neither pilot realized this and, as a result, improperly executed the vertical profile of the approach. The flight crossed an intermediate fix and the final approach fix hundreds of feet above the altitudes specified by the approach procedure.

The controller vectored the flight for the ILS Runway 6 circle-to-land to Runway 1 approach. But when the crew initiated the circle-to-land maneuver, the aircraft was 2.8 nm beyond the final approach fix and the crew was unable to line up with the landing runway. This should have prompted a go-around, NTSB said, but neither pilot called for one and the PIC—who by this time had taken control of the airplane—continued the approach. The aircraft, below approach speed, stalled and crashed one-half mile south of Runway 1.

Previously, the NTSB revealed that during the 30-minute cockpit voice recorder reading, the captain had uttered 131 expletives, 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,’” said John DeLisi, director of the NTSB’s Office of Aviation Safety, substituting the expletive with bleeping.

The NTSB said the accident highlighted four primary safety issues: the need for flight-data monitoring (FDM) programs in Part 135 operations; the need for the FAA to implement procedures to identify Part 135 operators whose pilots do not comply with standard operating procedures; the need for Part 135 operators to monitor pilots with performance deficiencies; and, the need for better guidance for Part 135 crew resource management (CRM).

The crash “raises important questions about what can be done to improve the safety of Part 135 operations,” NTSB chairman Robert Sumwalt said during the hearing on the investigation. “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.

The chairman pointed to FDM, CRM and safety management systems (SMS) and added, “If Part 135 aviation had the same tools as Part 121…we might not be here today.”

As a result of its findings, the NTSB issued three new recommendations, including a requirement for Part 135 operators to implement programs to provide additional training and oversight of crewmembers with demonstrated performance deficiencies. The NTSB also called for guidance for effective CRM training programs and for the FAA to review Learjet 35A operations manuals to determine whether they contain manufacturer-recommended approach speed wind additives.

The NTSB additionally reiterated six previous recommendations seeking mandatory flight-data monitoring, pilot leadership training programs, and SMS programs. Further, the recommendations call on the FAA to improve its oversight systems.