A Case of Unstabilized Approach

The accident report highlights the ­culture of omertà among professional pilots that keeps them from blowing the whistle on incompetent or unsafe colleagues.

The cockpit voice recorder transcript for the fatal flight revealed a surprising lack of professionalism. bomberpilot/Wikipedia

On a sunny afternoon in May 2017, a Learjet 35A on a Part 91 positioning flight from Philadelphia to Teterboro, New Jersey, crashed in an industrial area half a mile from the approach end of Teterboro’s Runway 1, killing both pilots.

It was a day of scattered clouds, good visibility and gusty northwest winds. A high probability of moderate low-level turbulence and wind shear had been forecast, and pilots were reporting 20-knot speed losses at nearby airports. Teterboro Tower issued warnings of gusts to 32 knots. The weather was consistent with the forecast, and though the Learjet pilots had not—as far as investigators could ascertain—obtained more recent weather information after their first briefing at 6:30 a.m., they knew what they needed to know.

The cockpit voice recorder transcript for the fatal flight revealed a surprising lack of professionalism. The captain seemed unaware of where the airplane was but kept up a profanity-filled dialogue with the second-in-command, who was the pilot flying—although, per company policy, he should not have been—but who appeared more like a ­bewildered student.

The captain, 53 years old, was a 6,900-hour ATP with 353 hours as PIC in the Learjet. He held SIC ratings for Beechjet 400 and Mitsubishi MU-300 and had flown right seat in those aircraft before his being hired as a PIC by the company that operated the accident Learjet. Upon being hired, he had gone to Learjet training in Dallas, where he had repeatedly been judged “not yet proficient” in a number of maneuvers, one of them being the circling approach.

He had successfully completed a proficiency check two months before the accident, but former colleagues, whom the National Transportation Safety Board interviewed afterward, described him as “ineffective” in the role of the “pilot monitoring” (what they used to call the pilot not flying) and not ready to be a PIC.

The right-seat pilot, 33, had 1,170 hours. He had gotten off to a somewhat rocky start in his flying career, failing his private check ride twice, but he was now a commercial pilot with single-engine and ­multiengine airplane, instrument, and Learjet SIC ratings. He still had problems, however. After a simulator session late in 2016, the instructor recorded a remarkable litany of faults, including not knowing how to start the engines, crashing on his first takeoff, going inverted during an unusual attitude recovery and crashing on landing during an ILS approach. Pilots who had flown with him described him as “­hit-or-miss” and error-prone.

When the wind is from the north or northwest at Teterboro, airplanes arriving from the south commonly use the Runway 6 localizer for guidance to the airport to stay clear of Newark, 12 nm to the south-southwest. They then “circle to land” on Runway 1. The expression “circle to land” does not imply actually circling. It just means that the landing runway is not the same as the runway whose approach guidance is used. A circling approach is, by definition, a visual approach; the pilot must have established “visual reference to the airport” before starting it. In this case, the circling maneuver would consist of a right turn of perhaps 30 degrees followed by a left turn of 90 degrees onto the extended centerline of Runway 1.

The straight-line distance from Philadelphia to New York is about 70 nm. Ten minutes after takeoff, New York Approach provided vectors for the ILS approach to Runway 6, ­circle to land on Runway 1. The captain commented: “He was saying circling —ing six or something. I don’t know what the — they thinkin’ we’re doin’. We’re —ing hundreds of miles away, man.” But in fact, at that point, they were 48 nm from Teterboro at 4,000 feet and traveling at 250 knots. One minute later, the PIC realized his mistake. “I gotta get the —ing ATIS. —. I didn’t realize we’re that —ing close. Of course, I don’t have —ing GPS, that’s why.”

When the rather lengthy ATIS came, however, the captain did not pay attention to it. “Information Zulu. Who the — knows what’s going on in Teterboro? Don’t have time to listen to it.”

Sixteen minutes after taking off from Philadelphia, the Learjet flew from west to east through the Runway 6 localizer. The approach controller pointed out the error and the crew corrected, eventually capturing the localizer 12 nm from the airport. Approach instructed them to “circle at TORBY”—the outer marker, 3.8 nm from the Runway 6 threshold.

At this point, the captain had become so preoccupied with talking the second pilot through the approach that he had lost situational awareness entirely. The Learjet did not turn at TORBY but instead continued straight down the localizer, neither pilot having apparently noticed the mistake.

When the Learjet was abeam the threshold of Runway 1, it began a descending right turn—although, at this point, there was no possibility of making a stabilized approach to the runway. Leveling out on a heading of approximately 145 degrees, it was at 350 feet and its speed had dropped to 123 knots, though the target speed should have been 139. Under company procedures, the crew should have begun a missed approach some time earlier—and certainly should have started one now—but neither pilot mentioned that possibility.

While the airplane was in the right turn, the second pilot, sounding stressed, turned over control to the captain, who now initiated a left turn, saying, “Watch my airspeed.”

“Lookin’ good,” the second pilot said. Then, “Add airspeed. Airspeed, airspeed…airspeed!”

“Stall,” the pilot said.

“Airspeed! Airspeed!”

The pilot pressed the mic button. “Ah, —,” he yelled.

The Learjet, whose stalling speed in a 35-degree banked turn should have been 102 knots, stalled at 111. The ­discrepancy could have been caused by a sudden control movement by the pilot or a lull in the north wind. The NTSB’s analysis of the pilot’s mental state during the turn is persuasive:

“Despite the SIC’s airspeed ­callouts, the PIC continued the left turn without adding power or lowering the ­airplane’s nose to reduce AOA. The PIC might not have processed the SIC’s callouts warning him that ­airspeed was decreasing due to a phenomenon known as inattentional deafness, in which pilots tune out critical auditory alerts in the cockpit during times of stress. ... As a result, the PIC’s announcement of “stall” might have been a response to the stall warning system’s stick-shaker activation rather than any of the SIC’s callouts. Although the AOA ­indicator would have depicted the decreasing stall margin, the PIC likely did not scan the AOA indicator because he was focused on the visual task of aligning the airplane with the landing runway. Thus, the NTSB concludes that the PIC’s focus on the visual maneuver of aligning the airplane with the landing runway distracted him from multiple indications of decreasing stall margin, resulting in an aerodynamic stall at low altitude.”

The NTSB’s 145-page report on the accident uncovers the wide gulf that sometimes exists between official operating procedures and actual conduct in the field—and the ­inability of FAA oversight to do much about it. It also highlights, as reports on accidents involving egregious pilot errors often do, the ­culture of omertà among professional pilots that keeps them from blowing the whistle on colleagues whom they consider incompetent or unsafe.

Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, "Technicalities" and "Aftermath," with FLYING readers.

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