CEN17MA183

NTSB accident investigation · Learjet 35A · Teterboro, NJ · May 15, 2017

Accident · FatalClass 1 · MajorFinal report
Date
May 15, 2017, 15:29 local (19:29 UTC)
Place
Teterboro, NJ
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N452DALearjet 35A
Defining event
Approach-circling (IFR): Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report March 26, 2019
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Central Region
Parties
Trans-Pacific Jets, NATCA, Honeywell, Teterboro FSDO, Bombardier
Safety recommendations
Yes
FAA report
20170515023049A
Case key
95175

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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 · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededGates Learjet 35A: 3 casesAll aircraft: 990 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · PilotGates Learjet 35A: 1 caseAll aircraft: 397 casesProbable cause
Planning/preparation: flight planning/navigationPersonnel issues › Task performance · Flight crewGates Learjet 35A: 1 caseAll aircraft: 179 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · OperatorGates Learjet 35A: 1 caseAll aircraft: 106 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorGates Learjet 35A: 1 caseAll aircraft: 61 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

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.

Factual narrative

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.

Aircraft

Registration
N452DA
Reported as
Learjet 35A
Category
Airplane
Serial number
35A-452
Built
1981
Airframe hours
11,441
Engines
Honeywell TFE731-2-2B, 1,550 lbs thrust, turbo fanHoneywell TFE731-2-2B, 1,550 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · February 15, 2017
Departed
PHL · Phillidelphia, PA
Destination
TEB · Teterboro, NJ
Flight plan
IFR
Airport
TEB · Teterboro, runway 01, 7,000 × 150 ft, asphalt
Equipment
Stall warning system, Auto-pilot, Angle of attack indicator

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Injuries
Fatal
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
6,800 total
Role
Co-pilot
Age
33
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Restraint
4-point
Toxicology
Performed
Flight hours
1,200 total

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 20 knots, gusting 30
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 43 °F
Altimeter
29.75 inHg
Observed at
TEB, 1 nm away

Docket · 68

The files NTSB released with the investigation on February 7, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.1 GB in all.

Cockpit voice recorder - group chairman's factual reportItem 1 · PDF · 60 pages · 715 KBOperations/human performance group chairman's factual reportItem 2 · PDF · 67 pages · 2.3 MBOperations attachment 1 - interview summariesItem 3 · PDF · 95 pages · 935 KBOperations attachment 2 - witness statementsItem 4 · PDF · 7 pages · 618 KBOperations attachment 3 - flight releaseItem 5 · PDF · 2 pages · 246 KBOperations attachment 4 - pilot pria recordsItem 6 · PDF · 13 pages · 1.7 MBOperations attachment 5 - captain recordsItem 7 · PDF · 32 pages · 26.9 MBOperations attachment 6 - captain previous employer recordsItem 8 · PDF · 60 pages · 30.7 MBOperations attachment 7 - SIC recordsItem 9 · PDF · 31 pages · 20.4 MBOperations attachment 8 - Bombardier Learjet 35 checklistsItem 10 · PDF · 10 pages · 451 KBOperations attachment 9 - duats flight plansItem 11 · PDF · 5 pages · 286 KBOperations attachment 10 - FAA FSDO correspondenceItem 12 · PDF · 14 pages · 16.1 MBOperations attachment 11 - charter informationItem 13 · PDF · 5 pages · 325 KBOperations attachment 12 - weight and balance informationItem 14 · PDF · 12 pages · 977 KBOperations attachment 13 - bed fuel analysisItem 15 · PDF · 17 pages · 809 KBOperations attachment 14 - crew schedulesItem 16 · PDF · 6 pages · 1.6 MBOperations attachment 15 - aircraft flight logsItem 17 · PDF · 12 pages · 33.9 MBOperations attachment 16 - trans-pacific lear 35A sops (excerpts)Item 18 · PDF · 28 pages · 514 KBOperations attachment 17 - cae lear 35A checklistsItem 19 · PDF · 4 pages · 478 KBOperations attachment 18 - CEN17FA183 - teb simulator observationItem 20 · PDF · 30 pages · 2.6 MBOperations attachment 19 - FAA circle approach guidanceItem 21 · PDF · 16 pages · 914 KBOperations attachment 20 - FAA terps change 21Item 22 · PDF · 19 pages · 1.6 MBOperations attachment 21 - teb protected airspace chartsItem 23 · PDF · 4 pages · 971 KBOperations attachment 22 - teb ILS06 flight inspectionItem 24 · PDF · 35 pages · 19.1 MBOperations attachment 23 - trans-pacific CRM trainingItem 25 · PDF · 17 pages · 885 KBOperations attachment 24 - party formsItem 26 · PDF · 3 pages · 4.2 MBOperations addendum 1 - FC-200 autopilot systemItem 27 · PDF · 33 pages · 979 KBOperations addendum 2 - cae lear 35 circling approach profileItem 28 · PDF · 2 pages · 201 KBOperations addendum 3 - trans-pacific CRM training (full version)Item 29 · PDF · 28 pages · 782 KBOperations addendum 4 - transpacific mission briefingItem 30 · PDF · 2 pages · 104 KBOperations addendum 5 - teb NOTAMItem 31 · PDF · 2 pages · 91 KBFAA responsesItem 32 · PDF · 6 pages · 870 KBAir traffic control group factual reportItem 33 · PDF · 9 pages · 142 KBAir traffic control addendumItem 34 · PDF · 2 pages · 96 KBAir traffic control attachment 1 - interview summariesItem 35 · PDF · 16 pages · 300 KBAir traffic control attachment 2 - figuresItem 36 · PDF · 9 pages · 1.9 MBAir traffic control attachment 3 - aircraft accident packageItem 37 · PDF · 65 pages · 11.5 MBAir traffic control attachment 4 - radar dataItem 38 · PDF · 8 pages · 754 KBAir traffic control addendum #2Item 39 · PDF · 2 pages · 95 KBAir traffic control attachment 5 - circling approach phraseology bulletinItem 40 · PDF · 3 pages · 1.5 MBAir traffic control natca certificate of party representativeItem 41 · PDF · 1 page · 3.5 MBRadar tracks of 56 aircraft that preceded N452DAItem 42 · PDF · 2 pages · 251 KBMeteorology factualItem 43 · PDF · 32 pages · 2.5 MBMeteorology attachment 1 - weather briefing documentsItem 44 · PDF · 7 pages · 574 KBMeteorology attachmetn 2 - pilot reports in raw formatItem 45 · PDF · 3 pages · 18 KBAirworthiness group factual reportItem 46 · PDF · 28 pages · 4.5 MBAirworthiness group attachment 1 - airplane manufacturer document excerptsItem 47 · PDF · 4 pages · 299 KBMaintenance recordsItem 48 · PDF · 27 pages · 344 KBEnhanced ground proximity warning system (EGPWS) - specialist's factual reportItem 49 · PDF · 15 pages · 11 photos · 8.1 MBEnhanced ground proximity warning system (EGPWS) - attachment 1 - tabular data (csv) - newItem 50 · CSV · 10 KBDigital electronic engine controls - specialist's factual reportItem 51 · PDF · 6 pages · 5 photos · 560 KBDigital electronic engine controls - attachment 1 - field notes (Honeywell)Item 52 · PDF · 10 pages · 16 photos · 4.5 MBDigital electronic engine controls - attachment 2 - field notes (microchip)Item 53 · PDF · 2 pages · 4 photos · 525 KBElectronic devices - specialist's factual reportItem 54 · PDF · 3 pages · 387 KBCockpit voice recorder sound spectrum study - group chairman's reportItem 55 · PDF · 7 pages · 608 KBSecurity video recordings - specialist's factual reportItem 56 · PDF · 7 pages · 1.7 MBSecurity camera video reel - updated versionItem 57 · MP4 · 257 MBRadar performance studyItem 58 · PDF · 16 pages · 12 photos · 2.9 MBAirplane performance study errataItem 59 · PDF · 4 pages · 953 KBRadar performance study addendumItem 60 · PDF · 4 pages · 309 KB
All 68 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.