“If Part 135 aviation had the same tools as Part 121,” including safety management systems (SMS), flight data monitoring (FDM), and crew resource management (CRM), “we might not be here today,” NTSB chairman Robert Sumwalt said this morning during a board meeting on the May 15, 2017 fatal crash of a Learjet 35A during an approach to Teterboro Airport. “This accident might never have happened.”
According to Sumwalt, “The pilots allowed the aircraft to stall, and they subsequently lost control of the aircraft as they were turning onto final approach while on a poorly flown circling approach.” The airplane struck a building and a parking lot and was destroyed by impact forces and a post-crash fire, killing both pilots.
The accident occurred on a Part 91 positioning flight that was operated by Part 135 operator Trans-Pacific Air Charter. The crash “raises important questions about what can be done to improve the safety of Part 135 operations,” said Sumwalt. “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.”
Sumwalt said the accident also highlights the problem of procedural non-compliance. “The captain of the flight disregarded company policy and allowed the second-in-command to be the pilot flying,” despite the latter not yet having enough experience necessary to operate the twinjet. In addition, he said, the pilot-in-command had not obtained the weather for the accident flight leg or conducted adequate preflight planning, nor did the pilots brief the approach during the flight.
“Furthermore, performance deficiencies that had been noted during the pilots’ initial training, were not being monitored by the company for recurrence. Safety programs used by Part 121 operators might have detected such deficiencies,” Sumwalt said. “Part 121 air carriers are required to have programs that ensure that performance deficiencies are corrected. To date, such programs are not required under Part 135.”
He also cited a lack of professionalism on the part of the crew. “Professionalism is a mindset that includes hallmarks such as precise checklist usage, precise callouts, and precise compliance with SOPs and regulations. Those traits were conspicuously absent on this flight.”
In addition, Sumwalt highlighted the pilot-in-command’s use of expletives as “just one symptom of a shocking lack of professionalism.” In fact, the cockpit voice recorder transcript contained 131 hashtagged expletives in a half hour, which “averages to one expletive every 14 seconds,” he said. “There are so many hashtags in this transcript, it reads like a social media feed.”
A “far more problematic issue” was the flight crew’s disregard for procedural compliance, noted Sumwalt. A previous NTSB study of more than 100 airline accidents “found that the highest-ranked accident prevention strategy was for pilots to follow standard operating procedures.”
Operators need to detect whether their pilots are complying with SOPs, but Part 135 operations do not have all the tools they need to ensure procedural compliance. These tools include SMS, FDM, and CRM, Sumwalt said.