Teterboro, New Jersey
February 2, 2005
NTSB Number: AAR-06-04
NTIS Number: PB2007-910401
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.
The National Transportation Safety Board determines that the probable cause of the accident was the pilots' failure to ensure the airplane was loaded within weight-and-balance limits and their attempt to take off 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.
The safety issues addressed in this report include weight and balance procedures; flight crew actions, training, and procedures; company oversight and operational control; FAA responsibility and oversight; cabin aide actions, training, and procedures; and runway safety areas.
As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
Disseminate to all principal inspectors of 14 Code of Federal Regulations Part 135 certificate holders and to all Part 135 certificate holders guidance that includes specific procedures, such as those contained in the draft revisions to Operations Specifications A-008, that detail appropriate methods by which a certificate holder can demonstrate to the Federal Aviation Administration that it is maintaining adequate operational control over all on-demand charter flights conducted under the authority of its certificate. This guidance should address operations based at locations geographically distant from the certificate holder's base, should be included in all Part 135 certificate holders' operations specifications, and should be required as periodic inspection items for principal inspectors. (A-06-66)
Review all charter management, lease, and other agreements between 14 Code of Federal Regulations Part 135 certificate holders and other entities to identify those agreements that permit and/or enable a loss of operational control by the certificate holder and require revisions of any such arrangements. (A-06-67)
Require all 14 Code of Federal Regulations Part 135 certificate holders to ensure that seatbelts at all seat positions are visible and accessible to passengers before each flight. (A-06-68)
Require that any cabin personnel on board 14 Code of Federal Regulations Part 135 flights who could be perceived by passengers as equivalent to a qualified flight attendant receive basic Federal Aviation Administraton-approved safety training in at least the following areas: preflight briefing and safety checks; emergency exit operation; and emergency equipment usage. This training should be documented and recorded by the Part 135 certificate holder. (A-06-69)