FlightFollowerFatal Learjet Crash Fueled by Pilot Errors and poor planning
The Learjet was less than a mile from the runway when the approach finally unraveled.
Ahead was Teterboro Airport in New Jersey. Behind the aircraft was a short, uneventful flight from Philadelphia. The weather was clear enough to see the airport, but strong northwest winds were gusting above 30 knots.
The crew had been given a demanding circle-to-land maneuver: fly the ILS approach to Runway 6, then circle visually and land on Runway 1.
Instead of beginning that maneuver where aircraft normally did, the Learjet continued toward the airport.
Air traffic control noticed.
The controller asked whether the crew was going to start the turn.
They began turning.
But the airplane was already too close, too low and too slow for a comfortable, stabilized alignment with Runway 1.
Inside the cockpit, the second-in-command repeatedly called attention to airspeed. The captain was trying to complete the landing. The Learjet rolled into a steep left turn at only about 450 feet above the ground.
The airspeed continued to fall.
One second later, the airplane rolled sharply to the right.
There was no time to recover.
At approximately 3:29 p.m. on May 15, 2017, Learjet 35A N452DA crashed into a commercial building and parking lot in Carlstadt, New Jersey, less than a mile from Teterboro Airport. Both pilots were killed. No one on the ground was injured. The aircraft was destroyed by impact forces and a post-crash fire. (NTSB)
The National Transportation Safety Board's final investigation found that this was not primarily a mechanical failure.
It was a breakdown in planning, cockpit discipline, procedure compliance and decision-making that culminated in an aerodynamic stall at low altitude. The NTSB report, CEN17MA183 / AAR-19/02, also identified weaknesses in the operator's safety programs and FAA oversight. (Library Online)
A Short Flight With a Long List of Problems
N452DA was a Learjet 35A operated by Trans-Pacific Air Charter, doing business as Trans-Pacific Jets.
The flight was a positioning leg from Philadelphia International Airport to Teterboro. There were no passengers aboard. The purpose was simply to reposition the aircraft for subsequent operations.
The distance was short—about 80 nautical miles—but the crew still filed an IFR flight plan requesting 27,000 feet. The flight ultimately lasted only about 25 minutes. (Library Online)
The captain was 53 years old and had approximately 6,898 hours of total flight experience, including 353 hours as a Learjet 35A pilot-in-command. He had recently moved into his first Part 135 captain position with the company.
There was an important difference between the two pilots' roles.
The second-in-command was authorized by company policy to act as pilot monitoring, not pilot flying.
Yet on this flight, the captain allowed him to fly the airplane.
That decision would become one of the central findings of the NTSB investigation. (Library Online)
The Copilot Was Flying
The cockpit voice recorder provided investigators with an unusually detailed picture of the flight.
Before takeoff, the captain instructed the second-in-command to put his hand on the yoke. After departure, the captain continued coaching him on aircraft control, trim, altitude and airspeed.
The NTSB determined that the second-in-command was acting as pilot flying even though company procedures did not authorize him to perform that role.
The problem was not simply that the captain handed over the controls.
The captain remained heavily involved in coaching the less-experienced pilot while simultaneously managing navigation, ATC communications and the approaching airport.
That blurred the normal division between pilot flying and pilot monitoring.
Instead of one pilot concentrating on flying while the other independently monitored the aircraft, both pilots became involved in the same tasks.
The NTSB later found that the captain's extensive coaching distracted him and interfered with the normal division of cockpit responsibilities. (Library Online)
That became particularly important once the approach grew complicated.
The Approach Was Not Properly Planned
The company's procedures required a mission briefing and flight planning before departure.
They also required an approach briefing for every approach and landing.
The approach briefing was supposed to cover items such as the approach procedure, navigation frequencies, altitudes, final approach fix, minimum descent altitude, missed approach point and any deviations from standard procedures. (Library Online)
That omission became significant because the Teterboro approach was not a simple straight-in landing.
Runway 1 was being used because of strong northwest winds. Aircraft approaching Teterboro from the southwest commonly flew the ILS to Runway 6 and then performed a circle-to-land maneuver to Runway 1.
The maneuver required the crew to leave the instrument approach at the appropriate point, maintain visual reference, turn away from the airport and then make another turn to align with Runway 1. (Library Online)
The accident crew did not have that preparation.
Strong Winds Were Waiting at Teterboro
The weather was visual, but it was not benign.
Surface observations around the accident time showed winds from roughly 310 to 340 degrees at 16–20 knots, with gusts reaching 32 knots.
Other pilots operating in the region reported severe turbulence and low-level windshear.
About 16 minutes before the crash, a regional jet near LaGuardia reported severe low-level windshear and an airspeed loss of approximately 20 knots.
About 10 minutes after the Learjet crash, another corporate aircraft near Morristown reported severe windshear with a similar 20-knot airspeed loss. (Library Online)
The wind therefore mattered.
The Learjet was approaching Runway 1 with a strong crosswind and gusts capable of rapidly changing the airplane's airspeed.
The NTSB later noted that manufacturer data did not fully account for the effect of gusts and control inputs on stall margin. (Library Online)
The Crew Gets Behind the Approach
As the Learjet approached Teterboro, the problems became increasingly visible in the cockpit recordings.
The captain realized they were close to the airport and expressed surprise at how quickly the flight had progressed.
He also realized that the airplane's GPS equipment was not available for the intended navigation task.
The crew then began setting up the ILS.
The controller instructed them to intercept the Runway 6 localizer.
They flew through it.
The controller had to remind them to intercept the localizer.
The crew also initially confused the visual scene around the New York airport complex, with the second-in-command identifying Newark rather than Teterboro.
The NTSB later found that the crew had not properly programmed the approach waypoints into the flight management system before descent, contrary to company policy. That failure likely contributed to their deteriorating positional awareness. (Library Online)
The approach was becoming a workload problem.
And workload was increasing precisely when the crew needed disciplined task division.
The Circle-to-Land Instruction
At about 3:23 p.m., the controller cleared the Learjet for the ILS Runway 6 approach with instructions to circle to Runway 1.
The crew acknowledged the clearance.
The controller also instructed the aircraft to maintain 240 knots until VINGS and then slow to 180 knots until TORBY, the final approach fix.
But the cockpit was still struggling to establish the correct vertical profile.
The airplane crossed DANDY significantly higher than intended.
It passed through the glideslope without properly capturing it.
The captain appeared confused about when the airplane could descend below 1,500 feet.
The crew crossed TORBY at approximately 1,550 feet, still above the desired profile.
Most importantly, they did not begin the circle-to-land maneuver at TORBY as instructed.
They continued beyond it.
The opportunity to make a normal, stabilized circle-to-land approach was disappearing.
ATC Notices the Problem
The controller was monitoring the aircraft.
The Learjet was now much closer to the airport than typical traffic conducting the maneuver.
Controllers expected aircraft to begin the circling maneuver several miles before the runway.
The accident airplane did not.
Contemporary reporting released shortly after the crash noted that radar showed the Learjet beginning its turn less than a mile from the approach end of the runway. (CBS News)
The crew responded that they were doing it.
The NTSB later concluded that the crew's failure to verify the approach and conduct an approach briefing had contributed to confusion about the vertical profile and the timing of the circle-to-land maneuver. (Library Online)
This is where the ATC audio becomes particularly revealing.
The controller was not unaware of the airplane.
He was watching it.
But ATC could not fly the circle-to-land maneuver for the crew.
Once the aircraft was visually maneuvering near the airport, the responsibility for maintaining a safe flight path remained with the pilots.
The Decision That Changed Everything
The Learjet eventually descended to the minimum descent altitude.
But by then, it was too far along the approach to comfortably make the required turns and establish a stabilized landing.
The airplane was about one mile from the Runway 6 threshold when the crew finally began the circling maneuver toward Runway 1. (Library Online)
The airplane descended below 500 feet.
The Enhanced Ground Proximity Warning System issued a 500-foot alert.
Seconds later came another warning: sink rate, pull up.
The aircraft was neither aligned with the runway nor stabilized.
Under company procedures, that should have meant a go-around.
The Learjet rolled wings level briefly and climbed about 100 feet.
The second-in-command again attempted to transfer control to the captain.
This time, the captain accepted.
The Final Turn
The captain began a rapid left turn toward Runway 1.
The second-in-command, now monitoring the flight, repeatedly called for additional airspeed.
Radar data indicated that the airplane reached approximately 35 degrees of left bank at 450 feet.
Then the captain announced "stall."
The second-in-command acknowledged the warning.
The airplane's calculated stall speed in a 35-degree level turn was approximately 102 knots. The radar-derived airspeed shortly before the crash was around 111 knots.
That might appear to leave a margin.
The aircraft was flying in gusty crosswind conditions. Control inputs required to maintain the turn could increase angle of attack on one wing. Gusts could also rapidly reduce airspeed.
The NTSB concluded that those factors could eliminate the apparent nine-knot margin and cause one wing to stall first. (Library Online)
The Crash
Security video captured the final seconds.
The airplane appeared in a steep bank, descending toward the industrial area.
No passengers were aboard, and no one on the ground was injured, although surrounding buildings and vehicles were damaged. Contemporary reports described a fire that damaged several buildings and numerous vehicles in the parking area. (CBS News)
The accident immediately prompted an investigation into the flight crew's final approach.
Investigators recovered the cockpit voice recorder, which became one of the most important pieces of evidence in reconstructing the accident. The NTSB later combined CVR information with radar data, ATC communications, aircraft-performance analysis and security video to reconstruct the final minutes. (NTSB)
The Training Warning Signs
The NTSB investigation went beyond the accident flight.
Both pilots had experienced difficulties during company training.
The second-in-command's simulator training records were especially concerning. During training, instructors documented problems with normal procedures, aircraft control, takeoff procedures, unusual attitudes and approaches.
He was initially graded not yet proficient during circle-to-land training and required four additional simulator sessions before being considered proficient. (Library Online)
The captain also required additional training during his qualification process.
Trans-Pacific knew that both pilots had experienced performance difficulties.
But after additional simulator training, the company did not establish an ongoing program to monitor whether those deficiencies had actually been corrected during line operations.
The NTSB found that some of the same performance problems identified during training appeared again during the accident flight. (Library Online)
This transformed the accident from a single bad approach into a much broader safety-management issue.
Poor Planning Was More Than a Checklist Omission
Calling the accident "poor planning" can sound simplistic.
The NTSB's findings were more specific.
The captain had not adequately prepared the approach.
The crew did not conduct the required approach briefing.
The pilots misunderstood portions of the vertical profile.
They failed to begin the circle-to-land maneuver at the appropriate point.
They continued an approach that no longer met the company's stabilized-approach criteria.
And they did not execute a go-around when multiple indications showed that the airplane was not in a safe position to land. (Library Online)
The accident therefore demonstrates how planning errors can compound.
One missing briefing does not normally cause an airplane to crash.
But a missing briefing can create confusion.
Confusion can increase workload.
Increased workload can lead to missed approach fixes.
Missed fixes can produce an unstable flight path.
And once the airplane is low, fast, slow or poorly positioned, the crew may feel pressure to salvage the approach rather than abandon it.
That is precisely what happened at Teterboro.
What the NTSB Concluded
The NTSB's final report identified the captain's decision to continue the approach as the immediate causal event.
The official probable-cause statement reads:
“The pilot-in-command’s (PIC) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.”
— National Transportation Safety Board, CEN17MA183 / NTSB/AAR-19/02. (Library Online)
The NTSB identified several contributing factors.
They included the captain's decision to allow an unapproved second-in-command to act as pilot flying, inadequate and incomplete preflight planning, and the crew's failure to conduct an approach briefing.
The investigation also found that the operator lacked safety programs capable of identifying and correcting patterns of poor performance and procedural noncompliance. The NTSB further found deficiencies in FAA oversight of the operator's safety systems. (Library Online)
The result was not one isolated pilot error.
Accident Facts
- Aircraft
- Learjet 35A
- Registration
- N452DA
- Operator
- Trans-Pacific Air Charter / Trans-Pacific Jets
- Date
- May 15, 2017
- Time
- About 15:29 EDT
- Location
- Carlstadt, New Jersey, near Teterboro Airport
- Departure
- Philadelphia International Airport
- Destination
- Teterboro Airport
- Operation
- Part 91 positioning flight
- Approach
- ILS Runway 6, circle to Runway 1
- Occupants
- 2
- Fatalities
- 2
- Survivors
- 0
- Ground fatalities
- 0
- Weather
- VMC; strong gusty northwest winds
- Defining event
- Aerodynamic stall during circling approach
- NTSB investigation
- CEN17MA183
- Final report
- NTSB/AAR-19/02
- Probable cause
- Attempt to salvage an unstabilized visual approach
Aviation Safety Network independently records the accident as a fatal Learjet 35A crash near Teterboro on May 15, 2017, with two fatalities and the aircraft operated by Trans-Pacific Jets. (Flight Safety Foundation)
The ATC Lesson
The Teterboro accident is particularly valuable when reconstructed through ATC audio because the controller's transmissions show the shrinking safety margin.
The controller provided speed restrictions.
The controller reminded the crew about the required altitude and circling point.
When the airplane did not begin the maneuver as expected, the controller asked whether the crew was going to start the turn.
But the critical decisions occurred inside the cockpit.
The controller could provide instructions and warnings, but he could not force the crew to execute a go-around.
The NTSB's analysis found that the accident resulted from the crew's failure to properly prepare and execute the approach, followed by the captain's decision to continue despite the unstable position. (Library Online)
This is an important distinction for an ATC-focused audience.
The radio calls are part of the story, but the investigation did not identify ATC as the primary cause.
Instead, the communications reveal how the cockpit and controller were increasingly operating from different pictures of the aircraft's situation.
What Changed After the Crash?
The NTSB made several safety recommendations following its investigation.
Among them were recommendations for Part 135 operators to establish programs for pilots who demonstrate performance deficiencies during training, develop stronger crew resource management programs, and improve flight data monitoring.
The NTSB also recommended safety-management-system requirements and stronger FAA procedures for identifying operators whose pilots were not complying with standard operating procedures. (Library Online)
The investigation also highlighted an issue specific to the Learjet 35A: approach-speed wind additives.
The manufacturer recommended adding speed in conditions where rapid or unexpected wind changes were possible. The NTSB recommended that operators' manuals incorporate appropriate guidance. (Library Online)
These recommendations demonstrate that the investigation was not simply about blaming two pilots.
The goal was to identify why the same chain of errors might occur again and how an operator or regulator could interrupt it earlier.
The Broader Aviation Safety Lesson
The Teterboro Learjet crash is a textbook example of why a stabilized approach is not a suggestion.
Once an approach becomes unstable, continuing does not make the situation safer.
It usually makes recovery harder.
In this case, the crew had multiple opportunities to stop the sequence.
The approach could have been briefed properly.
The navigation could have been programmed before descent.
The circle-to-land maneuver could have begun at the appropriate point.
The crew could have recognized that the aircraft was too far along the approach to safely line up with Runway 1.
The go-around criteria could have been applied when the aircraft descended below 500 feet without being stabilized.
And, finally, the captain could have rejected the landing attempt when the airspeed began to disappear during the final turn.
Each decision represented another opportunity to preserve the aircraft.
Instead, the crew continued.
The Learjet entered a steep low-altitude turn with decreasing airspeed and strong gusty winds. The stall warning came when there was almost no altitude left for recovery.
Two pilots died less than a mile from a runway they were trying to reach.
The lasting lesson is not that experienced pilots never make mistakes. They do.
The lesson is that professional aviation must be designed to stop mistakes from accumulating.
A briefing catches confusion.
A clear PF/PM division catches deviations.
A stabilized-approach policy provides an escape route.
A go-around prevents an unstable approach from becoming a landing attempt.
Effective training identifies weaknesses before they reach the cockpit.
And strong organizational oversight makes sure those safeguards actually work.
At Teterboro, too many of those barriers failed at the same time.
The final accident was an aerodynamic stall, but the chain began much earlier—with inadequate preparation, procedural noncompliance, poor cockpit coordination and the decision to salvage an approach that should have been abandoned.
That is the broader aviation safety lesson from N452DA: the safest landing is not always the one that reaches the runway. Sometimes the most professional decision is to go around while there is still plenty of altitude, airspeed and time left to try again.
Primary Source / Investigation Record
Investigation reference: CEN17MA183