The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Teterboro, New Jersey
Bombardier; Montreal, QC
Honeywell; Phoenix, Arizona
Trans-Pacific Jets
NATCA
Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
Location: Teterboro, NJ
Accident Number: CEN17MA183
Date & Time: 05/15/2017, 1529 EDT
Registration: N452DA
Aircraft: LEARJET 35A
Aircraft Damage: Destroyed
Defining Event: Aerodynamic stall/spin
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Positioning
Analysis
NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-19/02.
On May 15, 2017, about 1529 eastern daylight time, a Learjet 35A, N452DA, departed controlled flight while on a circling approach to runway 1 at Teterboro Airport (TEB), Teterboro, New Jersey, and impacted a commercial building and parking lot. The pilot-in-command and the second-in-command died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to A&C Big Sky Aviation, LLC, and was operated by Trans-Pacific Air Charter, LLC, under the provisions of Title 14 Code of Federal Regulations Part 91 as a positioning flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Philadelphia International Airport, Philadelphia, Pennsylvania, about 1504 and was destined for TEB.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot-in-command's (PIC) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude. Contributing to the accident was the PIC's decision to allow an unapproved second-in-command to act as pilot flying, the PIC's inadequate and incomplete preflight planning, and the flight crew's lack of an approach briefing. Also contributing to the accident were Trans-Pacific Jets' lack of safety programs that would have enabled the company to identify and correct patterns of poor performance and procedural noncompliance and the Federal Aviation Administration's ineffective Safety Assurance System procedures, which failed to identify these company oversight deficiencies.
Findings
Aircraft
Angle of attack - Capability exceeded (Cause)
Personnel issues
Incorrect action selection - Pilot (Cause)
Flight planning/navigation - Pilot (Cause)
Flight planning/navigation - Flight crew (Cause)
Organizational issues
Adequacy of policy/proc - Operator (Cause)
Oversight of operation - FAA/Regulator (Cause)
Factual Information
The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-19/02.
On May 15, 2017, about 1529 eastern daylight time, a Learjet 35A, N452DA, departed controlled flight while on a circling approach to runway 1 at Teterboro Airport (TEB), Teterboro, New Jersey, and impacted a commercial building and parking lot. The pilot-in-command and the second-in-command died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to A&C Big Sky Aviation, LLC, and was operated by Trans-Pacific Air Charter, LLC, under the provisions of Title 14 Code of Federal Regulations Part 91 as a positioning flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Philadelphia International Airport, Philadelphia, Pennsylvania, about 1504 and was destined for TEB.
History of Flight
Approach-circling (IFR)
Aerodynamic stall/spin (Defining event)
Loss of control in flight
Collision with terr/obj (non-CFIT)
Pilot Information
Certificate: Airline Transport; Commercial
Age: 53, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 02/28/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 6800 hours (Total, all aircraft)
Co-Pilot Information
Certificate: Commercial
Age: 33, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 10/13/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: 1200 hours (Total, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: LEARJET
Registration: N452DA
Model/Series: 35A
Aircraft Category: Airplane
Year of Manufacture: 1981
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 35A-452
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection: 02/15/2017, AAIP
Certified Max Gross Wt.: 18001 lbs
Time Since Last Inspection:
Engines: 2 Turbo Fan
Airframe Total Time: 11441 Hours as of last inspection
Engine Manufacturer: Honeywell
ELT:
Engine Model/Series: TFE731-2-2B
Registered Owner: A&C BIG SKY AVIATION LLC
Rated Power: 1550 lbs
Operator: On file
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As: Trans-Pacific Jets
Operator Designator Code: 1QUA
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: TEB, 8 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1452 EDT
Direction from Accident Site: 360°
Lowest Cloud Condition: Scattered / 4500 ft agl
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 20 knots / 30 knots
Turbulence Type Forecast/Actual:
Wind Direction: 350°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.75 inches Hg
Temperature/Dew Point: 19°C / 6°C
Precipitation and Obscuration: No Precipitation
Departure Point: Philadelphia, PA (PHL)
Type of Flight Plan Filed: IFR
Destination: Teterboro, NJ (TEB)
Type of Clearance: IFR
Departure Time: 1504 EDT
Type of Airspace:
Airport Information
Airport: Teterboro (TEB)
Runway Surface Type: Asphalt
Airport Elevation: 8 ft
Runway Surface Condition: Dry
Runway Used: 01
IFR Approach: Circling; ILS
Runway Length/Width: 7000 ft / 150 ft
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 2 Fatal
Latitude, Longitude: 40.829444, -74.060278
Jeffrey Alino
~
Jeffrey Alino, 33, of Union, New Jersey, was the first officer and William Ramsey, 56, of Salt Lake City, Utah, was the captain.
National Transportation Safety Board lead investigator Jim Silliman speaks at a press conference updating the status of the investigation into the plane crash that occurred in Carlstadt, New Jersey.
Adam Gerhardt, an air safety investigator with the National Transportation Safety Board, holds the cockpit voice recorder recovered from the wreckage of a fatal plane crash in Carlstadt on May 15, 2017.February 07, 2018
WASHINGTON (Feb. 7, 2018) — The National Transportation Safety Board opened the public docket Wednesday on its ongoing investigation of a Gates Learjet 35A crash that occurred during a circling approach to a runway at Teterboro Airport, Teterboro, New Jersey, killing both crewmembers.
The docket contains over 900 pages of factual information including: investigative group reports, witness statements, interview summaries and a transcript of the cockpit voice recorder. It does not provide analysis, findings, recommendations or probable cause determinations. No conclusions about how or why an accident occurred should be drawn from the docket.
The docket opening marks a transition in the investigative process where the majority of facts needed for the investigation have been gathered and the NTSB can move ahead with analysis of those facts. Opening the docket affords those with a need and desire for its contents the opportunity to review what factual information has been gathered about the accident. Any analysis, findings, recommendations, or probable cause determinations related to the accident will be issued by the Board at a later date.
The docket can be viewed at https://dms.ntsb.gov/pubdms
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Teterboro, New Jersey
Bombardier; Montreal, Quebec
Honeywell; Phoenix, Arizona
Aviation Accident Preliminary Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
http://registry.faa.gov/N452DA
Location: Teterboro, NJ
Accident Number: CEN17MA183
Date & Time: 05/15/2017, 1529 EDT
Registration: N452DA
Aircraft: GATES LEARJET 35A
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Positioning
On May 15, 2017, at 1529 eastern daylight time, a Gates Learjet 35A, N452DA, operated by Trans-Pacific Jets, departed controlled flight while on a circling approach to runway 1 at the Teterboro Airport (TEB), Teterboro, New Jersey, and impacted a commercial building and parking lot. The captain and first officer died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to A&C Big Sky Aviation LLC and operated by Trans-Pacific Air Charter LLC under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed from the Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, about 1504 and was destined for TEB.
The accident flight was the crewmembers' third flight of the day. The first flight departed TEB about 0732 on a Part 91 positioning flight and landed about 0815 at the Laurence G. Hanscom Field (BED), Bedford, Massachusetts, where they refueled and boarded a passenger. They departed BED about 1009 on a Part 135 on-demand charter flight and landed at PHL about 1104.
The captain filed an IFR flight plan to TEB planning a 28-minute flight at a cruising altitude of flight level 270 (27,000 feet) with a cruise speed of 441 knots and a departure time of 1430. After departure about 1504, the flight was cleared to climb to 4,000 feet above mean sea level (msl). The flight reached a maximum altitude of 4,000 feet msl. About 1515, the flight was cleared to descend to 3,000 ft msl. The New York Terminal Radar Approach Control (TRACON) cleared the flight for the TEB ILS Runway 6 Approach, circle to land runway 1. TRACON instructed the flight to switch frequencies and contact TEB air traffic control (ATC) about 9 miles from the airport; however, the flight did not check onto the ATC's frequency until 4 miles from the airport. ATC cleared the flight to land on runway 1 and issued the TEB winds of 320 degrees at 16 knots, gusting to 32 knots.
Radar track data indicated that the flight did not start its right circling turn until it was less than 1 mile from the approach end of runway 6. According to TEB ATC, aircraft typically start the right turn at the final approach fix for runway 6, which is located 3.8 nm from the approach end of runway 6.
A TEB ATC controller reported that he observed the airplane bank hard to the right and he could see the belly of the airplane with the wings almost perpendicular to the ground. The airplane then appeared to level out for just a second or two before the left wing dropped, showing the entire top of the airplane. Other ground witnesses also reported that they observed the airplane in a right turn with the wings in a high angle of bank. Some witnesses described seeing the airplane's wings "wobbling" before the left wing dropped and the airplane descended to the ground. Security video cameras installed at numerous commercial buildings also captured the last moments of the flight, showing the airplane at high angles of bank. One security camera showed the airplane in a steep right wing low, nose down attitude at impact.
The accident site was located on a 180-degree bearing about 1/2 nautical miles from the threshold of runway 1 at TEB. The main wreckage was distributed in the parking lots of commercial businesses. The wreckage path and debris field was about 440 ft. long on a 135-degree heading, and 3 buildings and 16 vehicles were damaged by impact or fire. Although impact forces and postcrash fire destroyed and consumed much of the airplane, the examination of the wreckage revealed that all components of the airplane were located at the accident site.
The cockpit voice recorder (CVR) was located in the wreckage and was sent to the National Transportation Safety Board's (NTSB) Vehicle Recorder Laboratory. The CVR was auditioned by NTSB senior management staff and found to be operating at the time of the accident. A CVR Group will be formed and a transcript of the flight will be produced.
Four other airplane components that store non-volatile memory (NVM) and an iPhone were collected and sent to the NTSB Vehicle Recorder Laboratory for examination. All 4 components and the iPhone exhibited impact and fire damage. The 4 components were: 2 Honeywell N1 Digital Electronic Engine Controls (DEEC); 1 Flight Management System (FMS); and 1 Honeywell KGP-56 Enhanced Ground Proximity Warning System (EGPWS).
At 1452, the surface weather observation at TEB was: wind 350 degrees at 20 knots gusting to 30 knots; 10 miles visibility; scattered clouds at 4,500 ft; temperature 19 degrees C; dew point 6 degrees C; altimeter 29.75 inches of mercury.
The TEB automated terminal information services (ATIS) Z was in effect at the time of the accident. The 1451 ATIS Information Z stated that the current weather was: wind 350 degrees at 18 knots gusting to 29 knots; visibility 10; light rain, 5,500 ft scattered; temperature 18 degrees C; dew point 6 degrees C; altimeter 29.74 inches of mercury. ILS Runway 6 circle approach in use…Low level wind shear advisory in effect… ."
Aircraft and Owner/Operator Information
Aircraft Manufacturer: GATES LEARJET
Registration: N452DA
Model/Series: 35A
Aircraft Category: Airplane
Amateur Built: No
Operator: Trans-Pacific Air Charter LLC
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As: Trans-Pacific Jets
Operator Designator Code: 1QUA
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: TEB, 8 ft msl
Observation Time: 1452 EDT
Distance from Accident Site: 1 Nautical Miles
Temperature/Dew Point: 19°C / 6°C
Lowest Cloud Condition: Scattered / 4500 ft agl
Wind Speed/Gusts, Direction: 20 knots/ 30 knots, 350°
Lowest Ceiling: None
Visibility: 10 Miles
Altimeter Setting: 29.75 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Philadelphia, PA (PHL)
Destination: Teterboro, NJ (TEB)
Wreckage and Impact Information
Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 2 Fatal
Latitude, Longitude: 40.829444, -74.060278
Reading the CVR transcript, I just wanted to cry from the very beginning.
ReplyDeleteCondition white. X2
ReplyDeleteI've run across this plane and its crew a couple times at various FBOs - very distinctive aircraft. Different crew each time I saw them (couple of years apart) but last was late 2016.
ReplyDeleteIf this was the same captain I met then - the guy was something else. Very arrogant, short tempered, and highly unprofessional. Girl at the front desk on that particular day had asked him if he wanted prist, which I perceived as a fairly innocent question. He then launched into tirade about how she was a complete idiot for not knowing a Lear 35 obviously takes positive prist. It went on for several minutes, transforming into various personal attacks on her and anyone within earshot who worked there, before he stormed out, slamming the door behind him. From the sound of it as they walked in afterward, various members of the ground crew had received similar treatment, and apparently had dealt with similar outbursts from him before. Number of passengers and other pilots were in the terminal and were fairly taken aback by his behavior.
Again, may not have been the same guy, but given the same aircraft and attitude of the captain in the reports - very sad outcome. That kind of attitude is a toxic environment for good CRM. Definitely feel bad for the SICs situation.
Well, they managed to crash a fully functional aircraft in good daylight conditions. Appalling airmanship.
ReplyDeleteRead the transcript with total incredulity; WTAF were they doing and, more importantly, what utter muppet let them loose in a lear?
ReplyDeleteMore rake is better.
ReplyDelete