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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.
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