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NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: October 31, 2006
SB-06-59
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IMPROPER LOADING CAUSED CRASH OF CORPORATE JET IN TETERBORO,
NEW JERSEY, NTSB FINDS
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Washington, D.C. - In a final report adopted today, the
National Transportation Safety Board determined that the
probable cause of a corporate jet accident, was the flight
crew's 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. The investigation revealed that
neither pilot used the available weight and balance
information appropriately to determine the airplane's weight
and balance characteristics for the take off.
"This accident clearly shows what can happen when
crucial operating steps are not adhered to," said NTSB
Chairman Mark Rosenker. "When it comes to transportation
safety there are no shortcuts and it is important that
operators and flight crews ensure that proper procedures are
followed at all times."
On February 2, 2005, a Bombardier Challenger CL-600-
1A11, during takeoff, ran off the departure end of runway 6
at Teterboro Airport, Teterboro, New Jersey; 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 Safety Board found that contributing to the
accident were Platinum Jet Management's (PJM) conduct of
charter flights without proper Federal Aviation
Administration (FAA) certification and its failure to ensure
that all for-hire flights were conducted in accordance with
Part 135 requirements. According to federal regulations, an
operator must hold an appropriate air carrier certificate to
operate as an air carrier and to advertise its services to
the public for compensation or hire. Although PJM did not
hold an appropriate certificate, the company advertised its
charter services and represented itself to the public as an
authorized charter operator, the Board found.
Another contributing factor was Darby Aviation's
(operating certificate holder) failure to maintain
operational control over 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. An example of this was the
Board's findings that PJM pilots routinely improperly
modified the airplane's weight and balance forms, using a
variety of invalid airplane empty weights to ensure that the
form indicated that the airplane was operating within its
limitations.
Also contributing to the cause was 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, the report
states. The Board noted that although FAA personnel
reviewed Darby's record, they did not ensure that PJM's
airplanes were operated and maintained in accordance with
Darby's company requirements or that charter trips flown by
PJM were controlled by Darby.
Finally, contributing to the accident was the FAA's
tacit approval of arrangements such as that between Darby
and PJM. The Board stated in its findings that without
clear and specific guidance on agreements between
certificate holders and other entities that provide
airplanes and/or flight crews for charter flights,
unauthorized entities could still be performing most, if not
all, of the functions of an on-demand charter operator
without controls, oversight, and demonstrations of fitness
imposed by a Part 135 certificate.
As a result of the investigation of this accident,
recommendations to the FAA includes:
* Reviewing all charter management, lease, and other
agreements between 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
* Requiring all Part 135 certificate holders to ensure
that seatbelts at all seat positions are visible and
accessible to passengers before each flight
* Requiring that any cabin personnel on board Part 135
flights who could be perceived by passengers as
equivalent to a qualified flight attendant receive
basic FAA-approved safety training in a least the
following areas (incomplete safety briefing was giving
on accident flight): 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 synopsis of the Board's report, including the
probable cause and recommendations, is available on the
Board's website, www.ntsb.gov. The Board's full report will
be available on the website in several weeks.
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Media Contact: Keith Holloway, (202) 314-6100
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