Blame Culture and Just Culture in Aviation Safety

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The NTSB has issued a preliminary report On the accident that occurred on January 31, 2025, at 1807 eastern standard time, involving a Learjet 55 airplane, Mexican registration XA-UCI (call sign MTS056) which was destroyed when it was involved in an accident in Philadelphia, Pennsylvania. The two pilots, two medical crewmembers, and two passengers were fatally injured. One person on the ground was fatally injured, 4 people were seriously injured, and 20 people incurred minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 129 air ambulance flight.
Preliminary ADS-B flight track data obtained from the Federal Aviation Administration revealed that the flight departed runway 24 at Northeast Philadelphia Airport (PNE), Philadelphia, Pennsylvania, about 1806, with the intended destination of Springfield-Branson National Airport (SGF), Springfield, Missouri. The airplane proceeded to the southwest before it turned right slightly and then entered a gradual left turn. The airplane continued in the left turn and reached an altitude of 1,650 ft mean sea level (airport elevation was 119 ft). The track data ended at 1807, at 1,275 ft msl, and at 242 knots ground speed. The duration of the flight was about 1 minute (see Figure 1).
The flight crew was in communication with the PNE air traffic control tower at the time of the accident and there were no distress calls received from the flight crew.
The airplane initially impacted a concrete sidewalk in a residential and commercial area. Security camera videos depicted a large explosion associated with the initial impact. The wreckage debris field was about 1,410 ft in length and 840 ft wide, oriented on a magnetic heading of about 150°. The airplane impacted a commercial sign during its descent, and the calculated descent angle based on the height of the observed damage to the sign was about 22°. The wreckage was highly fragmented. Wreckage and debris penetrated numerous homes, commercial buildings, and vehicles in the area, resulting in extensive fire and impact damage.
The NTSB, along with aviation safety experts from the Federal Aviation Administration (FAA) and Mexico’s Dirección de Análisis de Accidentes e Incidentes de Aviación (DAAIA), is conducting a thorough investigation. Key findings from the initial report include:
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