SMS Implementation: System Safety Tools for Improving Part 135 Operators’ Safety Culture

Main Article Content

Chien-tsung Lu
Anthony P. Carufe
Michael Ott
Adam E. Scott


On May 15, 2017, N452DA, a Learjet 35A operated by Trans-Pacific Air Charter, LLC, departed from Philadelphia to Teterboro, New Jersey and crashed south of Teterboro Airport (TEB) on a positioning flight under 14 Code of Federal Regulations Part 91 (Part 91) in Visual Meteorological Conditions (VMC). While circling to land Runway 01 after executing the Instrument Landing System (ILS) Runway (RWY) 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 prior to the accident, including deviations from air traffic control (ATC) clearances, company standard operating procedures (SOP), stabilized approach criteria without initiating a go-around, all of which contributed directly to the 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, using a group of practitioners’ perspectives, the authors used Fishbone Ishikawa Analysis and Fault Tree Analysis to discover upstream contributing factors followed by SMS implementation to improve the safety culture.

Article Details



CFR Chapter I Subchapter A. (n.d.)

Boeing (2012). Statistical summary of commercial jet airplane accidents.

Creswell, J. W., & Miller, D. L. (2000). Determining Validity in Qualitative Inquiry. Theory IntoPractice, 39(3), 124-130. doi:10.1207/s15430421tip3903_2

Ericson, C. A., II (2005). Hazard Analysis Techniques for System Safety. John Wiley &Son, Inc.

Federal Aviation Administration (FAA). (n.d.) About ASIAS.

FAA. (2016). Pilot’s Handbook of Aeronautical Knowledge. Washington, D.C.: Author.

FAA. (2004, April 4). Advisory Circular- Flight Operational Quality Assurance (FOQA).

FAA. (2015, January 8). AC 120-92B – Safety management systems for aviation service providers.

FAA. (2019, March 4). Safety Management System

SMS for 121 Operators.

FlightSafety International, Inc. (2011). Learjet 35/36 Pilot checklist and quick reference handbook (Change 2).

Global Aerospace. (2021). Vista Elite.

Goff, B. (2005). Estimating Determinants of Passenger Air Service to Small Markets. Urban Studies (Edinburgh, Scotland), 42(3), 557-565

International Business Aviation Council (IBAC). (2021). Benefits of IS-BAO.


International Civil Aviation Organization (ICAO). (2016) Annex 19 – Safety management (2nd ed.).

Ishikawa, K. (1990). Introduction to Quality Control. Florence, KY: Productivity.

Leib, S., & Lu, C-t. (2013). A Gap analysis of airport safety using ICAO SMS perspectives: A field study of Taiwan. Journal of Aviation Technology and Engineering 2:2 (2013) 63–70.

Lu, C-t. (2020, March). Research Reliability (R) and Validity (V) - Lecture, West Lafayette, IN.

Lu, C-t. (2021 August). Research design and data collection – Lecture. Purdue University, West Lafayette, IN.

Lu, C-t., Schreckengast, S., & Jia, J. (2011). Safety risk management, assurance and promotion: Hazard control system for budget-constrained airports. Journal of Aviation Technology and Engineering, 1(1), 1-15. DOI:

National Transportation Safety Board (NTSB). (2020). Data & stats.

National Transportation Safety Board (NTSB). (2019, March 12). Departure from controlled flight Trans-Pacific Air Charter, LLC Learjet 35A, N452DA.

Reason, J. (1997). Managing the Risk of Organizational Accidents. Aldershot, England: Ashgate.

Smith, D. (2006). Lecture notes on safety management systems. Aviation Safety Program Manager, Transportation Safety Institute.

United States Aircraft Insurance Group (USAIG). (2021). Performance vector plus.

Vincoli, J. W. (2014). Basic Guide to System Safety. Wiley.