NTSB · Safety Recommendation
Safety Recommendation A-19-008
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Develop guidance for Title 14 Code of Federal Regulations Part 135 operators to help them create and implement effective crew resource management training programs.
Safety Issue and Context
This report discusses the May 15, 2017, accident involving a Learjet 35A, N452DA, operated by Trans-Pacific Air Charter, LLC, that departed controlled flight while on a circling approach to runway 1 at Teterboro Airport, Teterboro, New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire.
Safety issues identified in this report include the need for flight data monitoring programs (and supporting recording devices) for 14 Code of Federal Regulations Part 135 operators; the need for safety management systems for Part 135 operators; the need for the Federal Aviation Administration (FAA) to develop and implement procedures to identify Part 135 operators whose pilots do not comply with standard operating procedures (SOP); the need for Part 135 operators to monitor pilots with performance deficiencies; inadequate FAA guidance for Part 135 crew resource management training; the need for leadership training for Part 135 PICs; and the lack of approach speed wind additive guidance in Trans-Pacific SOPs.
As a result of this investigation, the National Transportation Safety Board makes three new safety recommendations to the FAA, reiterates six safety recommendations, and reclassifies one recommendation.
Response History
October 23, 2023 · NTSB Correspondence · FAA
We note that the FAA determined this safety issue is adequately addressed in existing guidance material; therefore, you do not intend to develop the recommended guidance.
We point out that Advisory Circular (AC) 120.51E, CRM Training and AC-120-71B, Standard Operating Procedures (SOP) and Pilot Monitoring (PM) Duties for Flight Deck Crewmembers, were both available prior to this accident; however, the accident operator’s training materials did not explicitly state the importance of adhering to SOPs to facilitate effective teamwork, which was a major deficiency observed in the accident crew.
In addition, AC 120-51E makes extensive reference to line-oriented flight training (LOFT), which is described as “an extremely effective means of practicing CRM skills and receiving reinforcement” and is commonly used by Part 121 air carriers; however, LOFT is not commonly used among Part 135 operators. Therefore, we continue to believe clear guidance is needed that is specific to Part 135 operators and includes information on how to implement CRM training to effectively produce desired flight crew behaviors. Pending our review of such guidance, Safety Recommendation A-19-8 is classified OPEN-- UNACCEPTABLE RESPONSE.
May 3, 2023 · Recipient Response · FAA
-From Billy Nolen, Acting Administrator: The FAA considered providing additional guidance for air carriers for the development and implementation of Crew Resource Management (CRM) training programs. A review of available FAA guidance to assist operators in the creation and implementation of effective CRM programs includes these advisory circulars (ACs):