Improving Aviation Safety

How did a Learjet crash right across the street from its destination airport?

A few years ago, a charter Learjet crashed into a parking lot just across the street from Teterboro Airport located in New Jersey. The NTSB investigation of this accident took approximately a year and a half before the completed investigation dockets were publicly released in 2018. Flight planning errors, pilot monitoring, and overall situational awareness resulted in this accident.

On the day of the crash, the jet had taken off from Teterboro Airport early in the morning and had been serviced to various locations around the east coast before it was to ultimately return back to Teterboro for the night. Before the crew departed KTEB that morning, the pilot in command checked the weather only once during the entire time frame from when they departed KTEB that morning to when they were scheduled to return to KTEB later that evening. The charter company that the jet belonged to later confirmed that the pilot’s failure to have updated weather went against company policy, as they required that all of their pilots be briefed on current weather information no more than a few hours prior to departure. Although visual flight rules prevailed on this day, the pilot filed an instrument flight plan for the crew’s return to KTEB.

Investigators later discovered that the entries made in the flight plan, specifically the altitude and time en route, did not make sense, suggesting that the crew did not pay much attention to their flight brief and plan. Another piece of evidence that investigators found was in the cockpit voice recording tapes. It was found that the pilot in command of the plane was not actually the first officer but instead the second-in-command pilot. This also specifically went against the company’s policy as well because they prohibited the second-in-command pilot from being the primary pilot in control rather than just being coached by the first-in-command pilot. The air traffic controller had instructed the crew to execute their instrument landing to the runway six approach, then circle to KTEB’s runway one. Due to the crew’s improper flight plan entries, the crew began their landing maneuver too far away from the runway and would have been impossible to execute. Investigators concluded that at this point, the crew should have executed a go-around because the descent and landing procedures were not stable enough. However, neither of the pilots called for a go around and the plane’s airspeed continued to slow below standard approach speed at KTEB. When the jet began its final descending turn for the runway, it stalled due to the slow airspeed and crashed just short of runway one at KTEB (NTSB, 2018). Both of the pilots died. The explosion of the crash was heard all the way in Manhattan, New York, witnesses on the ground later explained.

At the time of the crash, winds were gusting around forty miles per hour, which may have aided in the stalling of the aircraft during its descent (Koloff, 2017). The main cause of this accident was the pilot’s attempt to continue on with an unstable approach which then induced a low-altitude stall. The contributing factors to this accident were determined to be the pilot flying the plane: the second in command was acting as the pilot in command which went against the company’s policies. The spotty preflight planning and improperly-entered instrument flight plan contributed to the lack of situational awareness in this accident.

Overall, safety was severely lacking leading up to this accident. Safety policy was not strong because the pilots were able to continue on with unsafe activity which then led to the crash of the jet. There were no risk control strategies in place because the pilots were not able to detect that their procedures were unsafe regardless of the meteorological conditions being deemed visual. After investigators assessed this crash, the need for a new and improved safety risk management system became clear. It was recommended that all crew members going forward be required to demonstrate proficiency and if they fail, proper training be addressed to correct for deficiencies in performance. The NTSB was detrimental in determining the cause of this accident and raising awareness to prevent similar accidents like this going forward.

References

Koloff, A. (2017, May 16). Two dead as plane crashes near Teterboro Airport. North Jersey Media Group. https://www.northjersey.com/story/news/bergen/carlstadt/2017/05/15/reports-plane-crashes-near-teterboro-airport-multiple-buildings-fire/323499001/

NTSB. (2018, February 7). Departure from controlled flight trans-pacific air charter, LLC Learjet 35A. CEN17MA183.aspx. https://www.ntsb.gov/investigations/Pages/CEN17MA183.aspx