Journal of Aviation/Aerospace Education & Research





Key words

SMS, Part 135, Safety Culture, FTA, Ishikawa Fishbone


On May 15th, 2017, N452DA, a Learjet 35A operated by Trans-Pacific Air Charter, LLC, departed from Philadelphia to Teterboro, New Jersey (TEB) on a positioning flight under 14 Code of Federal Regulations § 91 (Part 91) in Visual Meteorological Conditions (VMC). While circling to land Runway 01 at TEB after executing the Instrument Landing System (ILS) Runway 06 approach, N452DA stalled and crashed one-half mile south of the approach end of runway 01. The flight records indicated that the crew committed numerous errors before the accident, including deviations from air traffic control (ATC) clearances, company standard operating procedures (SOP), and stabilized approach criteria without initiating a go-around, all of which contributed directly to the fatal outcome. While the National Transportation Safety Board (NTSB) investigation issued several recommendations to the Federal Aviation Administration (FAA) and one recommendation for a change to the company’s SOP, this study used a group of practitioners’ perspectives, a Fishbone Ishikawa Analysis, and Fault Tree Analysis to reveal upstream contributing factors and made SMS implementation recommendations for an improved safety culture, which would likely have prevented the accident.



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