DCA05MA031

NTSB accident investigation · Bombardier CL-600-1A11 · Teterboro, NJ · February 2, 2005

Accident · Serious injuriesClass 1 · MajorFinal report
Date
February 2, 2005, 07:18 local (12:18 UTC)
Place
Teterboro, NJ
Injuries
4 serious, 9 minor; on the ground: 2 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N370VBombardier CL-600-1A11
Weather
Visual (VMC) · Dawn
Status
Completed · report February 1, 2007
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
AAI-100
Safety recommendations
Yes
FAA report
20050202003199A
Case key
60939

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 pilots' failure to ensure the airplane was loaded within weight and balance limits and their attempt to takeoff with the center of gravity well forward of the forward takeoff limit, which prevented the airplane from rotating at the intended rotation speed.

Contributing to the accident were: 1) PJM's conduct of charter flights (using PJM pilots and airplanes) without proper Federal Aviation Administration (FAA) certification and its failure to ensure that all for-hire flights were conducted in accordance with 14 CFR Part 135 requirements; 2) Darby Aviation's failure to maintain operational control over 14 CFR Part 135 flights being conducted under its certificate by PJM, which resulted in an environment conducive to the development of systemic patterns of flight crew performance deficiencies like those observed in this accident; 3) the failure of the Birmingham, Alabama, FAA Flight Standards District Office to provide adequate surveillance and oversight of operations conducted under Darby's Part 135 certificate; and 4) the FAA's tacit approval of arrangements such as that between Darby and PJM.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

OverrunTakeoff - aborted
Preflight planning/preparation - inadequateFlightcrewCause
Aircraft weight and balance - exceededFlightcrewCause
Rotation - not attainedFlightcrewCause
Information unclearCompany/operator managementCause
Inadequate surveillance of operationCompany/operator mgmtCause
InformationCompany/operator managementFactor
Inadequate surveillance of operationFaa(organization)Cause
InformationFactor
On ground/water encounter with terrain/waterTakeoff - aborted
Object - fence
Object - vehicle
Object - building(nonresidential)

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-06/04.

On February 2, 2005, about 0718 eastern standard time, a Bombardier Challenger CL-600-1A11, N370V, ran off the departure end of runway 6 at Teterboro Airport (TEB), Teterboro, New Jersey, at a ground speed of about 110 knots; through an airport perimeter fence; across a six-lane highway (where it struck a vehicle); and into a parking lot before impacting a building. 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. The airplane was destroyed by impact forces and postimpact fire. The accident flight was an on-demand passenger charter flight from TEB to Chicago Midway Airport, Chicago, Illinois. The flight was subject to the provisions of 14 Code of Federal Regulations (CFR) Part 135 and operated by Platinum Jet Management, LLC (PJM), Fort Lauderdale, Florida, under the auspices of a charter management agreement with Darby Aviation (Darby), Muscle Shoals, Alabama. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-06/04.

On February 2, 2005, about 0718 eastern standard time, a Bombardier Challenger CL-600-1A11, N370V, ran off the departure end of runway 6 at Teterboro Airport (TEB), Teterboro, New Jersey, at a ground speed of about 110 knots; through an airport perimeter fence; across a six-lane highway (where it struck a vehicle); and into a parking lot before impacting a building. 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. The airplane was destroyed by impact forces and postimpact fire. The accident flight was an on-demand passenger charter flight from TEB to Chicago Midway Airport, Chicago, Illinois. The flight was subject to the provisions of 14 Code of Federal Regulations (CFR) Part 135 and operated by Platinum Jet Management, LLC (PJM), Fort Lauderdale, Florida, under the auspices of a charter management agreement with Darby Aviation (Darby), Muscle Shoals, Alabama. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

Aircraft

Registration
N370V
Reported as
Bombardier CL-600-1A11
Category
Airplane
Airframe hours
6,900
Engines
Allied Signal ALF-502-L22, 7,500 lbs thrust, turbo fanAllied Signal ALF-502-L22, 7,500 lbs thrust, turbo fan
Damage
Substantial damage
Fire
On-Ground
Flight
Part 135
Operator
Platinum Jet Managment
Registered owner
DDH Aviation/448 Alliance
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 1, 2005 · 46 hours before
Departed
KTEB · Teterboro, NJ
Destination
KMDW · Chicago, IL
Flight plan
IFR
Airport
KTEB · Teterboro NJ, runway 6, 6,000 × 150 ft, asphalt

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
58
Injuries
Serious
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
15,060 total
Role
Co-pilot
Age
31
Injuries
Serious
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 1, 2004
Seat
Right
Toxicology
Performed
Flight hours
5,957 total

Weather

Conditions
Visual (VMC) · Dawn
Wind
10° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
21 °F, dew point 18 °F
Altimeter
30.53 inHg
Observed at
KTEB

Docket · 71

The files NTSB released with the investigation on October 31, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 69.5 MB in all.

Operation 2-factual report of group chairmanItem 1 · PDF · 21 pages · 387 KBOperations 2-attachmentsItem 2 · PDF · 472 pages · 21.6 MBOperations 2-factual errataItem 3 · PDF · 2 pages · 32 KBOperations 2-attachments addendum 1Item 4 · PDF · 15 pages · 941 KBOperations 2-attachments addendum 2Item 5 · PDF · 6 pages · 632 KBATC 3-factual report of group chairmanItem 6 · PDF · 6 pages · 110 KBATC 3-FAA aircraft accident packageItem 7 · PDF · 55 pages · 1.7 MBATC 3-addendum 1 noise abatement procedureItem 8 · PDF · 11 pages · 1.5 MBMeteorology 5-factual report of group chairmanItem 9 · PDF · 14 pages · 442 KBSurvival factors 6-factual report of group chairmanItem 10 · PDF · 53 pages · 722 KBSurvival factors 6-attachment 1-photographsItem 11 · PDF · 27 pages · 2.5 MBSurvival factors 6-attachment 2-PJM cabin aide documentsItem 12 · PDF · 9 pages · 446 KBSurvival factors 6-attachment 3-injury chartItem 13 · PDF · 2 pages · 34 KBSurvival factors 6-attachment 4-airport operations reportItem 14 · PDF · 4 pages · 152 KBSurvival factors 6-attachment 6-NTSB request for information and initial FAA responseItem 15 · PDF · 18 pages · 1.3 MBSurvival factors 6-attachment 7-subsequent FAA response to NTSB request for informationItem 16 · PDF · 3 pages · 135 KBSurvival factors 6-errata-addendumItem 17 · PDF · 1 page · 39 KBSurvival factors 6-telephone memorandum_ms dee buchananItem 18 · PDF · 1 page · 39 KBStructures 7-factual report of group chairmanItem 19 · PDF · 28 pages · 2.1 MBStructures 7-attachment 1Item 20 · PDF · 1 page · 1.1 MBStructures 7-attachment 2Item 21 · PDF · 1 page · 760 KBStructures 7-attachment 3Item 22 · PDF · 1 page · 778 KBStructures 7-attachment 4Item 23 · PDF · 1 page · 771 KBStructures 7-attachment 5Item 24 · PDF · 1 page · 832 KBStructures 7-attachment 6Item 25 · PDF · 1 page · 1.3 MBPowerplants 8-factual report of group chairmanItem 26 · PDF · 12 pages · 304 KBPowerplants 8-attachment 1_ saybolt laboratory certificate of analysis with results of fuel testsItem 27 · PDF · 2 pages · 67 KBSystems 9-factual report of group chairmanItem 28 · PDF · 19 pages · 1.4 MBSystems 9-factual report of group chairman addendum 1Item 29 · PDF · 13 pages · 969 KBFlight data recorder 10-SPECIALIST'S factual report of investigationItem 30 · PDF · 14 pages · 1.2 MBFlight data recorder 10-attachment 1_tabular listing for plots 1-3Item 31 · CSV · 8 KBFlight data recorder 10-attachment 2_tabular listing for plots 4-6Item 32 · CSV · 141 KBFlight data recorder 10-attachment 3_tabular listing for plot 7Item 33 · CSV · 28 KBFlight data recorder 10-SPECIALIST'S factual report of investigation addendum 1Item 34 · PDF · 1 page · 28 KBFlight data recorder 10-SPECIALIST'S factual report of investigation addendum 2Item 35 · PDF · 3 pages · 56 KBFlight data recorder 10-SPECIALIST'S factual report of investigation addendum 2 attachment 1_N370V flight logsItem 36 · PDF · 6 pages · 475 KBMaintenance records 11-factual report of group chairmanItem 37 · PDF · 15 pages · 139 KBMaintenance records 11-attachment 1 air carrier certificateItem 38 · PDF · 3 pages · 74 KBMaintenance records 11-attachment 2 airplane historyItem 39 · PDF · 2 pages · 40 KBMaintenance records 11-attachment 3 maintenance programItem 40 · PDF · 9 pages · 710 KBMaintenance records 11-attachment 4 supplemental type certificatesItem 41 · PDF · 6 pages · 237 KBMaintenance records 11-attachment 5 airworthiness directives and service bulletinsItem 42 · PDF · 20 pages · 1.9 MBMaintenance records 11-attachment 6 flight logsItem 43 · PDF · 2 pages · 121 KBMaintenance records 11-attachment 7 technical logsItem 44 · PDF · 4 pages · 358 KBMaintenance records 11-attachment 8 weight and balanceItem 45 · PDF · 11 pages · 697 KBMaintenance records 11-attachment 9 service difficulty reportItem 46 · PDF · 3 pages · 106 KBMaintenance records 11-attachment 10 major repairsItem 47 · PDF · 9 pages · 452 KBMaintenance records 11-attachment 11 vendor listingItem 48 · PDF · 2 pages · 44 KBMaintenance records 11-attachment 12 autopilot maintenance issueItem 49 · PDF · 4 pages · 207 KBMaintenance records 11-attachment 13 FAA work program and interviewsItem 50 · PDF · 16 pages · 670 KBCockpit voice recorder 12-factual report of group chairmanItem 51 · PDF · 37 pages · 331 KBCockpit voice recorder 12 - sound spectrum studyItem 52 · PDF · 3 pages · 199 KBAircraft performance 13-factual report of group chairmanItem 53 · PDF · 19 pages · 469 KBAircraft performance 13-simulator testItem 54 · PDF · 94 pages · 1.9 MBAircraft performance 13-errata-1Item 55 · PDF · 1 page · 13 KBAircraft performance 13-Bombardier performance studyItem 56 · PDF · 40 pages · 1.2 MBHuman performance 14-factual report of group chairmanItem 57 · PDF · 9 pages · 98 KBHuman performance 14-attachment 1Item 58 · PDF · 1 page · 429 KBHuman performance 14-attachment 2Item 59 · PDF · 1 page · 945 KBHuman performance 14-attachment 3Item 60 · PDF · 1 page · 19 KB
All 71 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.