Philadelphia

On May 15, 2017, about 1529 eastern daylight time, a Learjet 35A, N452DA, departed controlled flight while on a circling approach to runway 1 at Teterboro Airport (TEB), Teterboro, New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command (SIC) died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to A&C Big Sky Aviation, LLC, and was operated by Trans-Pacific Air Charter, LLC, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a positioning flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, about 1504 and was destined for TEB. The accident occurred on the flight crew’s third and final scheduled flight of the day; the crew had previously flown from TEB to Laurence G. Hanscom Field (BED), Bedford, Massachusetts, and then from BED to PHL. The PIC checked the weather before departing TEB about 0732; however, he did not check the weather again before the flight from PHL to TEB despite a company policy requiring that weather information be obtained within 3 hours of departure. Further, the crew filed a flight plan for the accident flight that included altitude (27,000 ft) and time en route (28 minutes) entries that were incompatible with each other, which suggests that the crew devoted little attention to preflight planning. The crew also had limited time in flight to plan and brief the approach, as required by company policy, and did not conduct an approach briefing before attempting to land at TEB. Cockpit voice recorder data indicated that the SIC was the pilot flying (PF) from PHL to TEB, despite a company policy prohibiting the SIC from acting as PF based on his level of experience. Although the accident flight waslikely not the first time that the SIC acted as PF (based on comments made during the flight), the PIC regularly coached the SIC (primarily on checklist initiation and airplane control) from before takeoff to the final seconds of the flight. The extensive coaching likely distracted the PIC from his duties as PIC and pilot monitoring, such as executing checklists and entering approach waypoints into the flight management system. Collectively, procedural deviations and errors resulted in the flight crew’s lack of situational awareness throughout the flight and approach to TEB. Because neither pilot realized that the airplane’s navigation equipment had not been properly set for the instrument approach clearance that the flight crew received, the crew improperly executed the vertical profile of the approach, crossing an intermediate fix and the final approach fix hundreds of feet above the altitudes specified by the approach procedure. The controller had vectored the flight for the instrument landing system runway 6 approach, circle to runway 1. When the crew initiated the circle-to-land maneuver, the airplane was 2.8 nautical miles (nm) beyond the final approach fix (about 1 mile from the runway 6 threshold) and could not be maneuvered to line up with the landing runway, which should have prompted the crew to execute a go-around because the flight did not meet the company’s stabilized approach criteria. However, neither pilot called for a go-around, and the PIC (who had assumed control of the airplane at this point in the flight) continued the approach by initiating a turn to align with the landing runway. Radar data indicated that the airplane’s airspeed was below the approach speed required by company standard operating procedures (SOPs). During the turn, the airplane stalled and crashed about 1/2 nm south of the runway 1 threshold.

Before pushback from the gate, the first officer, who was the pilot monitoring, initialized the flight management computer (FMC) and mistakenly entered the incorrect departure runway (27R instead of the assigned 27L). As the captain taxied onto runway 27L for departure, he noticed that the wrong runway was entered in the FMC. The captain asked the first officer to correct the runway entry in the FMC, which she completed about 27 seconds before the beginning of the takeoff roll; however, she did not enter the FLEX temperature (a reduced takeoff thrust setting) for the newly entered runway or upload the related V-speeds. As a result, the FMC's ability to execute a FLEX power takeoff was invalidated, and V-speeds did not appear on the primary flight display (PFD) or the multipurpose control display unit during the takeoff roll. According to the captain, once the airplane was cleared for takeoff on runway 27L, he set FLEX thrust with the thrust levers, and he felt that the performance and acceleration of the airplane on the takeoff roll was normal. About 2 seconds later, as the airplane reached about 56 knots indicated airspeed (KIAS), cockpit voice recorder (CVR) data indicate that the flight crew received a single level two caution chime and an electronic centralized aircraft monitoring (ECAM) message indicating that the thrust was not set correctly. The first officer called "engine thrust levers not set." According to the operator's pilot handbook, in response to an "engine thrust levers not set" ECAM message, the thrust levers should be moved to the takeoff/go-around (TO/GA) detent. However, the captain responded by saying "they're set" and moving the thrust levers from the FLEX position to the CL (climb) detent then back to the FLEX position. As the airplane continued to accelerate, the first officer did not make a callout at 80 KIAS, as required by the operator's standard operating procedures (SOPs). As the airplane reached 86 KIAS, the automated RETARD aural alert sounded and continued until the end of the CVR recording. According to Airbus, the RETARD alert is designed to occur at 20 ft radio altitude on landing and advise the pilot to reduce the thrust levers to idle. The captain later reported that he had never heard an aural RETARD alert on takeoff, only knew of it on landing, and did not know what it was telling him. He further said that when the RETARD aural alert sounded, he did not plan to reject the takeoff because they were in a high-speed regime, they had no red warning lights, and there was nothing to suggest that the takeoff should be rejected. The first officer later reported that there were no V-speeds depicted on the PFD and, thus, she could not call V1 or VR during the takeoff. She was not aware of any guidance or procedure that recommended rejecting or continuing a takeoff when there were no V-speeds displayed. She further said she "assumed [the captain] wouldn't continue to takeoff if he did not know the V-speeds." The captain stated that he had recalled the V-speeds as previously briefed from the Taxi checklist, which happened to be the same V-speeds for runway 27L. The captain continued the takeoff roll despite the lack of displayed V-speeds, no callouts from the first officer, and the continued and repeated RETARD aural alert. FDR data show that the airplane rotated at 164 KIAS. However, in a postaccident interview, the captain stated that he "had the perception the aircraft was unsafe to fly" and that he decided "the safest action was not to continue," so he commenced a rejected takeoff. FDR data indicate that the captain reduced the engines to idle and made an airplane-nose-down input as the airplane reached 167 KIAS (well above the V1 speed of 157 KIAS) and achieved a 6.7 degree nose-high attitude. The airplane's pitch decreased until the nose gear contacted the runway. However, the airplane then bounced back into the air and achieved a radio altitude of about 15 ft. Video from airport security cameras show the airplane fully above the runway surface after the bounce. The tail of the airplane then struck the runway surface, followed by the main landing gear then the nose landing gear, resulting in its fracture. The airplane slid to its final resting position on the left side of runway 27L. The operator's SOPs address the conditions under which a rejected takeoff should be performed within both low-speed (below 80 KIAS) and high-speed (between 80 KIAS and V1) regimes but provide no guidance for rejecting a takeoff after V1 and rotation. Simulator testing performed after the accident demonstrated that increasing the thrust levers to the TO/GA detent, as required by SOPs upon the activation of the "thrust not set" ECAM message, would have silenced the RETARD aural alert. At the time of the accident, neither the operator's training program nor manuals provided to flight crews specifically addressed what to do in the event the RETARD alert occurred during takeoff; although, 9 months before the accident, US Airways published a safety article regarding the conditions under which the alert would activate during takeoff. The operator's postaccident actions include a policy change (published via bulletin) to its pilot handbook specifying that moving the thrust levers to the TO/GA detent will cancel the RETARD aural alert. Although simulator testing indicated that the airplane was capable of sustaining flight after liftoff, it is likely that the cascading alerts (the ECAM message and the RETARD alert) and the lack of V-speed callouts eventually led the captain to have a heightened concern for the airplane's state as rotation occurred. FDR data indicate that the captain made erratic pitch inputs after the initial rotation, leading to the nose impacting the runway and the airplane bouncing into the air after the throttle levers had been returned to idle. Airbus simulation of the accident airplane's acceleration, rotation, and pitch response to the cyclic longitudinal inputs demonstrated that the airplane was responding as expected to the control inputs. Collectively, the events before rotation (the incorrect runway programmed in the FMC, the "thrust not set" ECAM message during the takeoff roll, the RETARD alert, and the lack of required V-speeds callouts) should have prompted the flight crew not to proceed with the takeoff roll. The flight crewmembers exhibited a self-induced pressure to continue the takeoff rather than taking the time to ensure the airplane was properly configured. Further, the captain initiated a rejected takeoff after the airplane's speed was beyond V1 and the nosewheel was off the runway when he should have been committed to the takeoff. The flight crewmembers' performance was indicative of poor crew resource management in that they failed to assess their situation when an error was discovered, to request a delayed takeoff, to communicate effectively, and to follow SOPs. Specifically, the captain's decision to abort the takeoff after rotation, the flight crew's failure to verify the correct departure runway before gate departure, and the captain's failure to move the thrust levers to the TO/GA detent in response to the ECAM message were all contrary to the operator's SOPs. Member Weener filed a statement, concurring in part and dissenting in part, that can be found in the public docket for this accident. Chairman Hart, Vice Chairman Dinh-Zarr, and Member Sumwalt joined the statement.

During landing at its home airport, the airplane overran the runway and traveled down a 40-foot embankment before coming to rest against trees and sustaining substantial damage. According to the pilot, his speed on approach was a little fast but he thought it was manageable. Recorded data from the accident airplane revealed that 20 seconds before touchdown, when the pilot selected flaps 30 (landing flaps) the airspeed was approximately 27 knots above the maximum flap extension speed, and as the airplane touched down its airspeed was approximately 14 knots higher than specified for landing. The runway had a displaced threshold with 3,097 feet of runway length available. Skid marks from the accident airplane began approximately 868 feet beyond the displaced threshold, and continued for about 2,229 feet until they left the paved portion of the runway.

During the takeoff roll, after the pilot disengaged the nose gear steering, the airplane began to turn to the right. The copilot noticed fluctuations with the engine indications, and called for an abort. Power was reduced to idle, and the pilot corrected to the left using left rudder pedal and braking. The airplane turned to the right again, and the pilot corrected to the left. The airplane continued to turn left, and departed the left side of the runway, tail first, and was substantially damaged. The airplane had accrued 18,040.3 total hours of operation. It was powered by two turbofan engines, each equipped with an electronic fuel computer. Examination of the left engine's wiring harness revealed that the outer shielding on the fuel computer harness assembly was loose, deteriorated, and an approximate 3-inch section was missing. Multiple areas of the outer shielding were also chaffed, the ground wire for the shielding was worn through, and the wiring was exposed. Testing of the wiring to the fuel computer connector, revealed an intermittent connection. After disassembly of the connector, it was discovered that the connector pin's wire was broken off at its crimp location. Examination under a microscope of the interior of the pin, revealed broken wire fragments that displayed evidence of corrosion. Simulation of an intermittent electrical connection resulted in N1 spool fluctuations of 2,000 rpm during engine test cell runs. According to the airplane's wiring maintenance manual, a visual inspection of all electrical wiring in the nacelle to check for security, clamping, routing, clearance, and general condition was to be conducted every 300 hours or 12 calendar months. Additionally, all wire harness shield overbraids and shield terminations were required to be inspected for security and general condition every 300 hours or 12 calendar months, and at every 600 hours or 24 calendar months. According to company maintenance records, the wiring had been inspected 6 days prior to the accident.

On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport, Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Night visual conditions prevailed at the time of the accident.

The pilot was finishing his third round-trip, Part 135 cargo flight. The first round trip began the previous evening, about 2150, and the approach back to the origination airport resulted in a landing on runway 15R at 2305. The second approach back to the origination airport resulted in a landing on runway 28 at 0230. Prior to the third approach back to the airport, the pilot was cleared for, and acknowledged a visual approach to runway 33R twice, at 0720, and at 0721. However, instead of proceeding to the runway, the airplane flew north of it, on a westerly track consistent with a modified downwind to runway 15L. During the westerly track, the airplane descended to 700 feet. Just prior to an abeam position for runway 15L, the airplane made a "sharp" left turn back toward the southeast, and descended into the ground. Witnesses reported the airplane's movements as "swaying motions as if it were going to bank left, then right, and back left again," and "the nose...pointing up more than anything...but doing a corkscrew motion." Other witnesses reported the "wings straight up and down," and "wings vertical." Tower controllers also noted the airplane to be "low and tight," and "in an unusually nose high attitude close to the ground. It then "banked left and appeared to stall and then crashed." A post-flight examination of the wreckage revealed no evidence of mechanical malfunction. The pilot, who reported 6,800 hours of flight time, had also flown multiple round trips the previous two evenings. He had checked into a hotel at 0745, the morning prior to the accident flight, checked out at 1956, the same day, and reported for work about 1 hour before the first flight began.

The aircraft experienced an uncontained failure of the high pressure turbine stage 1 disk in the No. 1 engine during a high-power ground run for maintenance. Because of a report of an in-flight loss of oil, US Airways mechanics had replaced a seal on the n°1 engine’s integral drive generator and were performing the high-power engine run to check for any oil leakage. For the maintenance check, the mechanics had taxied the airplane to a remote taxiway on the airport and had performed three runups for which no anomalies were noted. During the fourth excursion to high power, at around 93 percent N1 rpm, there was a loud explosion followed by a fire under the left wing of the airplane. The mechanics shut down the engines, discharged both fire bottles into the No. 1 engine nacelle, and evacuated the airplane. Although both fire bottles were discharged, the fire continued until it was extinguished by airport fire department personnel. The aircraft was damaged beyond repair.

The airplane departed at night after maintenance was performed on the left engine. The pilot attempted to return to the airport and while on base leg struck the ground inverted and nose down. The left engine propeller was found feathered. On the left engine, the # 5 cylinder was off the engine and the # 5 piston with the connecting rod still attached were found nearby. Interviews revealed that during maintenance, the # 1,3,5,and 6 cylinders had been removed and reinstalled; however, the # 5 cylinder had not been tightened. Several people had worked on the airplane at various stages of the work. The maintenance facility did not have a system to pass down what had been accomplished, and the FAA did not require the tracking of work accomplished in other than 14 CFR Part 121, or 14 CFR Part 145 facilities.

During an attempted takeoff, the airplane collided with a taxiway sign, a fence, a light pole and came to rest between two buildings. According to the pilot in command (seated in the right seat), a preflight and run-up inspection was completed successfully. He stated that a pilot rated passenger (in the left front seat) was following along with a placard checklist. He stated that the airplane was accelerated for takeoff on runway 7, and at 500 feet down the 2700 foot long runway with the airspeed at redline, rotation was initiated and the airplane veered to the right. He stated that shortly thereafter the right engine surged and he noted the matched power levers, but he did not record the engine power instruments. A passenger (seated in a forward facing seat behind the pilot in command) reported that the pilot rated passenger's hand was on the throttle(yellow-knobbed handles) at the time of the accident The reported visibility was 1/8 mile in fog. The prescribed takeoff minimums for that airport is 400 feet and 1 mile visibility. Post accident examination of the engines and their systems revealed no evidence of preimpact mechanical malfunction. The pilot reported that there was no mechanical malfunction.

The pilot took off on runway 07 and was cleared direct to the Wiscasset NDB, east of the airport. Shortly after takeoff, the airplane began turning to the left. The pilot then asked the controller, '. . . can you tell if I'm in a turn? I have a problem here.' Soon thereafter, the airplane collided with terrain in an uncontrolled descent, about 1.6 miles north of the airport. Investigation revealed that three days before the accident, a refueler had fueled the airplane's left wing with 840 pounds of fuel, then the fuel farm ran out of fuel. No further fueling was accomplished, and the pilot was not advised of the uneven fuel load. Procedures in the Beech E90 Pilot's Operating Manual (POM) included a check of the fuel tanks during preflight. The Beech C90 POM specified a maximum fuel imbalance of 200 pounds, but the E90 POM did not specify a maximum fuel imbalance. During examination of the wreckage, no preimpact malfunction or failure was found.