With private aviation flight crew safety remaining an NTSB priority, David Lawrence, a senior accident investigator with the agency, used a case study of a recent accident during a Business Aviation Safety Summit webinar this morning to illustrate why it has urged the adoption of flight data monitoring (FDM) and safety management systems (SMS) for operators.
The example Lawrence chose was the May 15, 2017 crash of a Learjet 35A on approach to Teterboro Airport that claimed the lives of the pilot and copilot. The jet was on a short positioning flight from Philadelphia to Teterboro, and Lawrence cited a litany of mistakes from the crew, including ignoring checklists, filing an improper flight plan, disregarding standard operating procedures, failure to follow ATC instructions, and poor airmanship.
Among the evidence cited by Lawrence was the PIC’s request on the flight plan for an altitude of 27,000 feet, which couldn’t have been achieved during such a short flight. While the second-in-command was designated SIC-0, intended to only monitor the flight, the NTSB said he was on the controls for the entire flight, save for the final fateful 15 seconds when the PIC belatedly took over. Lawrence described the SIC's performance based on his ATC interactions as weak. A review of the ATC log showed the crew disregarded instructions to circle to Runway 1; a last-minute attempt to correct that error caused an unrecoverable stall.
Post-accident investigation revealed the operator had no SMS or any formal safety structure, and no way of ascertaining if its crews were following SOPs, which is a reoccurring problem among Part 135 operators, according to Lawrence. He noted that pilots who deviate from SOPs are three times more likely to commit errors and that half of all CFIT accidents involve failure to adhere to them.
As well, both pilots had had multiple training and certification difficulties, yet there was no evidence that the operator had monitored their inflight performance. “Safety is not stagnant,” Lawrence said. “Safety and risk management is something that you do continually.”