Did you ever have the feeling you were reading about a pilot who was deliberately tempting fate in some sort of game of chicken, to see how far he could go to boost his own feelings of superiority while dismissing mistakes and disregarding procedures that were put into place to help ensure disciplined scenarios? That's the way the NTSB”s report on the crash of a Learjet 35A at Carlstadt, New Jersey, on May 15, 2017, unfolded for me. While the Safety Board found that factors unrelated to pilot actions contributed to the accident, none was more disturbing than what the pilot-in-command (PIC) did and did not do.
The NTSB found that the probable cause of the accident was PIC's attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude. Contributing factors were his allowing an unapproved second-in-command (SIC) to be actually flying the airplane, his inadequate and incomplete preflight planning, and the pilots not doing an approach briefing. In addition, the Safety Board found that the operator of the plane, Trans-Pacific Air Charter LLC, did not have in place safety programs that would have enabled it to identify and correct patterns of poor performance and failure to comply with procedures on the part of its pilots. The Safety Board also faulted the FAA's ineffectiveness in identifying the operator's oversight deficiencies. While the probable cause is a mouthful, it's the factual report and analysis that contains the really jaw-dropping details.
The 10-seat jet was manufactured in 1981. Two Honeywell TFE731-series engines provided the power. The airplane had plenty of gadgets, including the dual HSIs for the pilot and co-pilot and a flight management system (FMS) that included a GPS-driven navigation computer unit. The control display for the FMS was mounted in the console between the pilot seats, so either pilot had ready access.
The accident flight was the airplane's third flight of the day. The first flight began with a 7:32 a.m. departure from Teterboro en route to Hanscom Field in Bedford, Massachusetts (KBED). Investigators found that the pilot had checked the weather at about 6:37 that morning. At that time, the Teterboro outlook at flightime was VFR with scattered clouds at 6,000 feet and winds at 20 knots gusting to 32 knots.
The Lear arrived at KBED at 8:15 and was supposed to pick up one passenger to go to Philadelphia International Airport (KPHL) in Pennsylvania. However, when it got to KBED, three passengers were waiting. It took some time to handle the situation, and the plane did not get out of KBED until 10:09 a.m., almost an hour after its planned departure time. There was no record of either of the pilots checking the weather before departure, as required by company procedures. The flight arrived at KPHL at about 11:04 a.m. After the passengers were dropped off, the flight crew had a bit of a layover.
At about 2:15 p.m., the PIC's DUATS account was used to file an IFR flight plan from KPHL to KTEB. It's presumed that the pilot did the filing because it was his account that was used. There was nothing to indicate that whoever filed the flight plan used the session for a weather briefing, and the NTSB had no evidence that the pilot checked the weather somewhere else. The distance as the crow flies between the two airports is only about 91.8 miles. The flight plan called for a flying time of 28 minutes with a requested cruise altitude of FL 280. Requesting an altitude like that for a trip from KPHL to KTEB could reflect wishful thinking, a misunderstanding of how things usually work in the congested real world of northeast airspace—which is not likely because the pilot was no stranger to operations there—or something akin to sloppiness.
When one of the pilots called clearance delivery at KPHL at about 2:33, he was given clearance to KTEB via the Philadelphia One standard departure, with a climb to 3,000 feet and to expect clearance to climb to 4,000 feet 10 minutes after departure. So much for FL 280.
The flight received clearance to taxi to Runway 35 from the ground controller, and, at 3:00:51, the PIC told the SIC, “Okay, I think we're next man. Hand on your yoke.” The SIC, however, was only qualified under company policy to perform the duties of a “pilot monitoring,” not a “pilot flying.” And the flight was supposed to be a positioning flight, not an instructional flight.
The 33-year-old SIC held a commercial certificate with an instrument rating and a Lear type rating. He had 1,167 hours, with 407 as SIC. The 53-year-old PIC held an airline transport pilot certificate, first-class medical, and was current and qualified under FAA and company requirements with about 6,898 total flight hours and 353 hours as a Lear PIC.
The airplane's cockpit voice recorder (CVR) captured the PIC coaching the SIC in applying power. He was heard calling out 80 knots, V1 and rotate during the takeoff sequence. At 3:04:18, the PIC told the SIC he should have given the PIC two instructions. “Gear up. Yaw dampener engaged. Ya gotta tell me to do that,” the PIC said. At 3:04:40, the PIC told the SIC, “If you'd like the autopilot engaged you can go ahead and do it at this time.” The airplane was handed off to the departure controller, and the PIC reported in at 2,000 feet. The controller cleared them to climb and maintain 4,000 feet and handed them off to Philadelphia Approach Control.
The pilots were alerted to a VFR Grumman aircraft, which they did not see, and were given a turn off course for sequencing. Their conversation included complaints about the way they were being handled and kept at low altitude.
The PIC continued to coach the SIC in flying the airplane, including issuing several reminders about the 250 knots airspeed restriction at low altitude. At 3:09:35, the controller asked, “What's your airspeed?” The CVR picked up what sounded like a decrease in engine thrust about a second before the PIC admitted to the controller that they had been at 260 knots. The CVR picked up the SIC saying, “Come on baby, slow down for me,” followed by, “There we go.” The PIC commented, “I don't think we'll be violated for that.” Then, apparently referring to the airspeed, he said, “That's good. Just right there. It'll bleed off a little.”
At about 3:12, the PIC radioed the controller asking for a higher altitude. “I would have to spin you back around and sequence you with the rest of the traffic goin' into Teterboro,” the controller replied. “It's like she doesn't like us,” the SIC said. The pilots continued discussing airspeed, and the PIC noted that they were dealing with a tailwind and, “You have to pull back the power ju-u-u-st a little.” The pilots complained to each other about their course and altitude, and, at 3:13:16, the PIC said of the controller, “She's a (expletive) idiot. Get us someone else if she can't do it."
The flight was handed off to New York Approach Control, and, at 3:13:58, they were given the Newark Liberty International Airport altimeter setting and told to fly a heading of 020 as a vector to the ILS approach to Runway 6, to be followed by circling to land on Runway 1 at Teterboro. The PIC missed the heading and asked the SIC what it was, but, before the SIC could tell him, radioed the controller to ask for a repeat of the altimeter setting. Instead of the heading, the SIC gave him the altimeter setting 29.75, and after the controller replied with a repeat of both the altimeter setting and the vector, the SIC said, “Zero two zero on the heading.”
At about 3:14:47, the CVR picked up the PIC making a comment that could support the NTSB's feeling that he didn't really understand the route they were on and their position on the route. “He was saying circling (expletive) six or something. I don't know what the (expletive) they thinkin' we're doin'. We're (expletive) hundreds of miles away, man.” They were, in fact, about 20 miles away at that point.
At 3:15:13, the controller radioed for them to descend and maintain three thousand, and the PIC acknowledged. The CVR recorded him saying, “Let's go down to three,” followed by, “We're (expletive) gonna be there in ten minutes,” followed by, “I gotta get the (expletive) ATIS (expletive). I didn't realize we're that (expletive) close.” The PIC didn’t listen to the whole ATIS. He turned it down, giving the SIC only the altimeter setting at TEB.
The Safety Board said that although the pilots had been alerted to expect the ILS to Runway 6 with circle to Runway 1, what was on the CVR indicated the PIC was not clear about the approach. He did not ask the controller about the approach, and the crew did not conduct an approach briefing, which company procedures require. The CVR did not record them running a descent checklist as required by company procedures, but it did pick up the PIC at 3:17:59 saying, “Let’s do the checklist.” However, neither was heard calling out a checklist. The only thing remotely resembling it was when the PIC said, “Approach is one twenty-six. V-ref is one-nineteen,” apparently referring to speeds.
The Safety Board said cockpit conversations that showed apparent confusion about approach waypoints also indicated that the pilots had not programmed the approach waypoints into the FMS, as required by company procedures.
At 3:19:17, the controller told them to fly 090 degrees to intercept the Runway 6 localizer. About a minute later, the airplane flew through the localizer, and the SIC told the PIC, “Runway in sight.” According to radar, at that time, the airplane was 30 miles from KTEB. While the controller gave them a left turn to 020 for the localizer, the pilots were still trying to figure out why they weren’t intercepting it, and the SIC admitted that he had mistaken Newark International Airport for Teterboro. At 3:21:09, they captured the localizer, and the SIC confirmed that the navigation mode had been selected on the FMS. At 3:23:23, the controller told them to cross the VINGS fix, 12.4 nautical miles (nm) out on the ILS approach to Runway 6, at 2,000 feet, that they were 8 miles from VINGS, and they were cleared for the ILS Runway 6 approach, circle to land on Runway 1. The readback was correct, and the controller asked for their airspeed. The PIC replied that it was 240 knots, and the controller told him to maintain 240 until reaching VINGS, then slow to 180 knots until reaching TORBY, the final approach fix (FAF). The PIC reminded the SIC to hold 240 and 2,000 feet and that the circling minimum was 760 feet.
What followed was a lot of chatter about where they were and what the SIC had to do. At about 3:25:08, the PIC said, mistakenly, “Hey, we’re tracking the V-O-R inbound now,” subsequently correcting himself to “localizer.” A few seconds later, he said they were over VINGS, and the SIC should pull the power to idle. Then he said, “No, no no, no don’t (expletive) do that yet. We haven’t captured the glideslope.”
At 3:26:21, the PIC called for landing checks, but there was no indication any sort of checklist was run. At 3:26:32, the controller told them to contact the tower and be sure to cross another fix, DANDY, 6.4 nm out, at 1,500 feet. The PIC read it back as 200 feet, and the controller corrected him. The PIC then twice told the SIC to cross DANDY at 1,500 feet. Then, the CVR recording showed they didn’t know where they were with respect to DANDY. Investigators found that one of the VOR receivers was not tuned to the Teterboro VOR, which it would have had to be in order for the pilots to identify DANDY. The NTSB found that they crossed DANDY at 2,050 feet instead of 1,500 and flew through the glideslope without capturing it and descending. The PIC called for SIC to “…trim the nose over.”
By 3:28:17, the airplane had crossed the outer marker/FAF TORBY too high. The pilots were talking back and forth about altitude and what to do and had not yet contacted the tower as instructed. The approach controller again instructed them to call the tower.
When the PIC finally called the tower, the controller advised the wind was from 360 degrees at 16 knots, gusting to 32 knots. The PIC was told to continue for Runway 1 and that traffic was holding in position.
While the pilots did have the benefit of being able to look out the window and see where they were, what was on the CVR indicated there was tension and confusion and conflict. Neither had a full grasp of the navigation needed for the approach procedure, and the SIC kept falling behind the airplane.
At about 3:29:07, the tower controller asked if they were going to start their circling procedure to line up for Runway 1. The airplane was about a mile from the threshold for Runway 6 when the PIC radioed, “We’re doin’ it right now.” The CVR indicated the PIC directed the SIC on making a right turn, holding airspeed and keeping a safe altitude. At 3:29:15, the SIC tried to get the PIC to take the controls, but the PIC didn’t respond. The ground proximity warning system then issued an alert, which the PIC told the SIC to ignore: “Sink rate. Pull up.” Investigators say the plane then rolled wings level and pulled up about 100 feet. The SIC said, “I’m gonna give ya your controls, okay?” The PIC agreed to take the controls and, according to the NTSB, sounded angry. What happened next indicates that instead of being angry, he would have been better served to be sensible, abandon the approach, fly the missed approach and start fresh.
Radar data indicated that the plane began to turn left and slowed. Now, with the airplane tight to the field, the SIC warned they were at V-ref speed. Four times he called for the PIC to add airspeed. The airplane reached a left bank of 35 degrees and slowed to about 111 knots, still above the calculated stall speed of 102 knots. But the wind was gusty, and investigators determined that the gustiness affected the flight characteristics and put the plane into a stall. In three seconds beginning at 3:29:40, the CVR recorded the PIC saying “stall,” the SIC calling for airspeed and the ground proximity warning system shrieking “Sink rate. Pull up.” The PIC yelled an expletive over the radio, and that was that.
A witness said the airplane made two dramatic turns, the second of which was to line up for Runway 1. Other witnesses saw it nearly inverted, with its nose low before impact about a half mile from the runway. The impact and post-crash fire damaged or destroyed three buildings and 16 vehicles. The pilots were the only fatalities.
While the NTSB was highly critical of both pilots, its findings specifically faulted the PIC for inadequate and incomplete preflight planning, the improper decision to allow the SIC to fly, coaching the SIC to the point it interfered with normal duties, not catching that the stall margin was vanishing and, to top everything off, continuing the approach even though it did not meet the company's stabilized approach criteria and the airplane was not in a position to make a safe landing.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.