There is plenty of blame to go around on this accident, everything from the crew's inability to deal with passenger pressure to get into a day-only airport after sunset, to a poorly worded NOTAM forbidding circling approaches at night when those were the only kind of approaches available.

— James Albright

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Updated:

2014-03-26

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Yes, the crew flew the instrument approach poorly by violating several step down altitudes, but the worst offense in my view was both pilots had their eyes outside while nobody was inside flying the airplane. Had they had a robust set of mandatory callouts, the pilot flying would have had greater confidence "staying inside" while the other pilot remained outside.

1 — Accident report

2 — Narrative

3 — Analysis

4 — Cause

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1

Accident report

  • Date: 29 MAR 2001
  • Time: 19:01
  • Type: Gulfstream Aerospace G-1159 Gulfstream III
  • Operator: Avjet Corp
  • Registration: N303GA
  • Fatalities: 3 of 3 crew, 18 of 18 passengers
  • Aircraft Fate: Destroyed
  • Phase: Approach
  • Airports: (Departure) Los Angeles International Airport, CA (LAX) (LAX/KLAX), United States of America; (Destination) Aspen Airport, CO (ASE) (ASE), United States of America

2

Narrative

About 1200 (1100 Pacific standard time), the first officer contacted the Hawthorne, California, Automated Flight Service Station (AFSS) specialist for a weather briefing. A review of the audiotape indicated that the specialist informed the first officer of three National Weather Service (NWS) AIRMETs [Airman's Meteorological Information pertinent to the flight to ASE, an 1141 weather observation for ASE, and the ASE forecast for 1300 to 1900. The specialist also informed the first officer that the approach procedure had been updated and that circling minimums were no longer authorized at night. During the briefing, the first officer filed the flight plan, identifying Garfield County Regional Airport in Rifle, Colorado, as the alternate airport.

The airplane's departure from LAX at 1711 (1611 Pacific standard time) was 41 minutes later than originally scheduled because of the late arrival of the passengers, including the charter customer. The flight was planned for 1 hour 35 minutes, so the estimated arrival time at ASE was 1846, 12 minutes before the airport's nighttime landing curfew.

Statements early in the cockpit voice recorder (CVR) recording indicated that the flight crew was aware of the nighttime landing restriction at ASE. The CVR transcript indicated that, about 1831:06, the captain stated, "well, there's the edge of night right here." About 1831:24, the first officer asked the captain about the time of official sunset for ASE. The captain replied "six twenty eight" and then stated, "so we get thirty minutes after sunset. So six fifty eight . . . about . . . seven o'clock." About 1837:04, the first officer called for the approach briefing. The captain then stated, "we're . . . probably gonna make it a visual . . . if we don't get the airport over here we'll go ahead and shoot that approach . . . and . . . we're not going to have a bunch of extra gas so we only get to shoot it once and then we're going to Rifle." The first officer acknowledged this information.

About 1844:22, the first officer made initial contact with ASE approach control. About 1844:43, the flight crew heard, over the ASE approach control frequency, the request of a Canadair Challenger 600 airplane, N527JA, for another approach to ASE. The approach controller then cleared N527JA to continue on the published missed approach procedure. About 1845:00, the first officer stated, "I hope he's doing practice approaches." About 3 seconds later, the captain asked the controller whether the pilot of N527JA was practicing or had actually missed the approach. The controller replied that the pilot had missed the approach and indicated that he had seen the airplane at 10,400 feet.10 The controller also informed the captain that two other airplanes were on approach to ASE. About 1845:32, the controller instructed the flight crew to turn to a 360º heading for vectors for the approach sequence.

While the airplane was descending into the terminal area, the CVR recorded the flight crew discussing the location of a highway near the airport. About 1845:45, the captain stated, "where's that . . . highway? can we get down in there?" About 11 seconds later, the captain stated, "can you see?" and the first officer stated, "I'm looking I'm looking . . . no." About 1846:26, the captain indicated, "I got it," and, about 2 seconds later, he asked the first officer, "can't really see up there can ya?" The first officer replied, over the next several seconds, "nope not really" and "I see a river but I don't see nothing else." About 1847:19, the first officer stated, "I see . . . some towns over here and the highway's leading that way but I'm not sure."

About 1847:30, the approach controller made a blanket broadcast that the pilot of an airplane (a Cessna Citation, N900MF) saw the airport at 10,400 feet and was making a straight-in approach, to which the first officer stated, "ah, that's good." (This airplane landed without incident at the airport about 10 minutes before the accident.) About 1847:41, the captain informed the controller that, "I can almost see up the canyon from here but I don't know the terrain well enough or I'd take the visual." About 1847:51, the first officer stated, "could do a contact but . . . I don't know," followed by his statement, "probably we could not." The first officer also stated, about 1848:04, "remember that crazy guy in this Lear[jet] when we were . . . on the ground in Aspen last time and he [stated that he could] see the airport but he couldn't see it." The captain did not respond to either of the first officer's statements.

About 1848:51, the captain stated, "there's the highway right there." The first officer then asked the captain if he wanted to be set up on the approach, and the captain indicated that he was ready. About 1849:28, the captain asked the first officer whether he could see the highway, to which the first officer replied, "no it's clouds over here on this area I don't see it." About 1850:42, the captain stated, "but it's right there." About 6 seconds later, he stated, "oh I mean we'll shoot it from here I mean we're here but we only get to do it once." About 1850:54, the captain indicated to the flight attendant that, if the attempt to execute the approach was not successful, they would have to go to Rifle because "it's too late in the evening then to come around."

About 1851:54, the approach controller instructed the flight crew to turn to a heading of 050º. About 1853:09, the approach controller instructed the flight crew to turn to a heading of 140º to intercept the final approach course and maintain an altitude of 16,000 feet. Afterward, the controller made a blanket broadcast that the last airplane (a Canadair Challenger 600, N898R) had missed the approach, to which the first officer remarked, "that's . . . not . . . good."

About 1853:57, the flight attendant asked whether a male passenger could sit on the jumpseat in the cockpit. About 11 seconds later, the flight attendant instructed that passenger to make sure his seatbelt was on, and the CVR recorded a sound consistent with a seatbelt buckle. About 1855:05, the flight crew heard, over the approach control frequency, the pilot of N898R transmit his intention to execute a missed approach. Afterward, the captain stated, "the weather's gone down they're not making it in," and an unidentified male voice in the cockpit stated, "oh really."" The approach controller subsequently cleared N898R to continue on the missed approach procedure.

About 1856:06, the approach controller cleared the flight crew for the VOR/DME-C approach,13 advised the crew that the airplane was 5 miles from the Red Table VOR (the initial approach fix), and instructed the crew to cross the VOR at or above an altitude of 14,000 feet. The first officer acknowledged this information.

About 1856:23, the first officer said, "after VOR you are cleared to twelve thousand seven hundred." About 1856:42, the approach controller made a blanket broadcast that ATIS information India was current and that the visibility north of the airport was 2 miles. The approach controller then instructed the flight crew to contact ASE local control, and the crew established contact with the local controller about 1857:28. The local controller informed the flight crewmembers that they were following a Challenger airplane (N527JA) that was 2 miles from the runway, reported the wind at 240º at 5 knots, and cleared the airplane to land on runway 15. About 1857:55, the first officer acknowledged the clearance to land. The captain then asked the first officer for the DME at the 12,700-foot step-down fix. The first officer replied, 3 DME (south of the Red Table VOR).

About 1858:00, the local controller asked the pilot of N527JA whether he had the airport in sight, to which he replied, "negative, going around." About 1858:13, an unidentified male voice in the cockpit asked, "are we clear?" The captain replied, "not yet" and "the guy in front of us didn't make it either." About 1858:27, the captain asked the first officer about the next step-down altitude, and he answered that it was 12,200 feet. The first officer also indicated that the next step-down fix was at 6 DME (south of the Red Table VOR). (This step-down fix, ALLIX, is the final approach fix and the beginning of the final approach segment.) About 1859:11, the captain asked the first officer about the next step-down altitude, and the first officer answered, 10,400 feet.

About 1859:30, the captain called for the landing gear, and the CVR recorded the sound of two "clunks" and an increase in background noise immediately afterward. The captain called for landing flaps about 1859:34, and the CVR recorded a "click" and a "clunk" sound about 2 seconds later. About 1859:39, the first officer indicated that the step-down fix at 10,400 feet was 9.5 DME (south of the Red Table VOR). About 1859:46, the first officer stated, "three greens." About 1900:04, the first officer indicated that the missed approach point was 11 DME (south of the Red Table VOR). About 1900:08, an unidentified male voice in the cockpit stated, "snow." About 1900:22, when the airplane was at an altitude of 10,400 feet, the captain stated, "okay . . . I'm breaking out,"" and asked the local controller, about 5 seconds later, whether the runway lights were all the way up. The controller indicated, "affirmative they're on high." About 1900:30, the first officer said, "okay you can go . . . ten thousand two hundred [the minimum descent altitude]."

About 1900:43, the captain asked the first officer whether he could see the runway, and the CVR recorded an unintelligible statement made by the first officer about 2 seconds later. About 1900:46, when the airplane was at an altitude of 10,000 feet, the captain asked the first officer whether he could see the highway, and he replied, about 1 second later, "see highway."" The local controller asked the flight crewmembers, about 1900:49, whether they had the runway in sight. About 2 seconds later, the first officer stated, "affirmative," and the captain stated, "yes now yeah we do." About 1 second afterward, the first officer advised the controller that the runway was in sight. About 1901:13, the first officer stated, ". . . to the right is good." According to radar data, the airport was to the left of the airplane at this time.

About 1901:21, the CVR recorded a sound consistent with the airplane's configuration alarm, which continued for 9 seconds. About 1901:28, the CVR recorded the airplane's flight profile advisory (FPA) unit announce the 1,000-foot callout, and the first officer stated, "one thousand to go." About 1901:31 and 1901:34, the CVR recorded the sound of the FPA's 900- and 800-foot callouts, respectively. About 1901:36, the captain stated, "where's it at?" The CVR recorded the FPA's 700- and 600-foot callouts about 1901:38 and 1901:42, respectively. About 1901:42, the first officer stated, "to the right," which the captain repeated about 1 second later. Radar data indicated that the airport was still to the left of the airplane at this point.

About 1901:45, the CVR recorded the airplane's GPWS and FPA unit simultaneously announce the 500-foot callout. According to radar data, the airplane started a turn to the left about 1901:47. About 1901:49, the GPWS announced a sink rate alert, and the FPA announced the 400-foot callout. About 1901:52, the CVR again recorded a GPWS sink rate alert and the FPA 400-foot callout. Also, the CVR recorded a rumbling noise that continued until the end of the recording. According to the CVR Sound Spectrum Study performed for this accident, the engines increased to maximum power about 1901:53. The FPA 300-foot callout was recorded about 1901:54, and the GPWS and FPA 200-foot callouts were recorded about 1 and 2 seconds later, respectively. About 1901:57, the CVR recorded the GPWS bank angle alert when the airplane was banked about 40º left wing down

The airplane crashed into terrain while in a steep left bank about 2,400 feet short of the runway 15 threshold, 300 feet to the right (west) of the runway centerline and 100 feet above the runway threshold elevation. The accident occurred at 39º14.315 minutes north latitude and 106º 52.637 minutes west longitude. The time of the accident was 34 minutes after official sunset. The CVR stopped recording about 1901:58.

Source: NTSB Accident Brief


3

Analysis

Charter information.

The business assistant of the client who chartered N303GA stated, in a postaccident interview, that his employer had chartered the airplane because he was hosting a party in Aspen. The business assistant indicated that Avjet called him about 1630 and informed him that the passengers were not at the airport and that the latest time the airplane could depart was 1655. He stated that he immediately began to track down the passengers and found out that all but two (including his employer) were in the airport parking lot. The charter department scheduler who handled N303GA on the day of the accident indicated that she told the business assistant that the flight would instead have to go to the airport at Rifle if the two passengers did not arrive shortly.

According to the business assistant, the passengers that had arrived boarded the airplane. The business assistant indicated that one of the pilots had spoken to one or more passengers and stated that the airplane might not be able to land at ASE because of the nighttime landing curfew. The charter customer, upon learning about this conversation, instructed his business assistant to call Avjet and relay a message to the pilot that he should "keep his comments to himself."

The business assistant stated that, when he told his employer about the possibility that the flight might have to divert, his employer became "irate." According to the business assistant, he was told to call Avjet and tell the company that the airplane was not going to be redirected. Specifically, he was told to say that his employer had flown into ASE at night and was going to do it again. The business assistant stated that he called Avjet to express his employer's displeasure about the possibility of not landing in ASE.

The charter department scheduler who handled N303GA on the day of the accident indicated that the captain stated, during an en route conversation about 1830, that it was important to land at ASE because "the customer spent a substantial amount of money on dinner."

Source: NTSB Accident Brief

Execution of the instrument approach procedure

According to the intent of the NOTAM, the instrument approach procedure to ASE was not authorized after 1855. As a result, the flight crew should not have been attempting this procedure to the airport.

The airplane crossed the Red Table VOR about 1857:49 at an airspeed of 160 knots and then crossed the step-down fix about 1858:40 at an airspeed of 150 knots. However, by this time, the flight crew could no longer comply with the local regulation that required the airplane to be on the ground by 1858.

After passing ALLIX, the airplane maintained a descent rate of about 2,200 feet per minute and an airspeed of about 125 knots. When the airplane reached altitudes of 11,200, 10,700, and 10,300 feet, Avjet's Operations Manual required the first officer to callout, "1000 to go [until landing minimums]," "500 to go," and "approaching minimums," respectively. However, the CVR did not record any of these callouts.

The airplane began to descend again about 1900:49 at a rate of 2,200 feet per minute. The local controller noticed that the airplane had prematurely descended below the 10,400-foot step-down altitude and asked the flight crewmembers whether they had the runway in sight. About 1900:51, the first officer and the captain stated, almost simultaneously, "affirmative" and "yes now yeah we do,"" respectively. These statements were communicated only to the other pilot, but, about 1 second later, the first officer informed the controller that the runway was in sight. Radar data indicated that the airplane was at an altitude of 9,750 feet at the time but that it had not started maneuvering toward the airport.

Evidence indicated that, at that point, the flight crew probably did not have the runway in sight or had it in sight only briefly.

About the same time as the airplane passed the missed approach point, the captain asked, "where's it at?"" This statement suggests that the captain had not identified, or had lost visual contact with, the runway. At this point, the captain should have abandoned the approach, especially because the airplane was close to the ground in mountainous terrain.

Source: NTSB Accident Brief

Pressure on the flight crew

The charter customer's communications both before and during the flight, stressing the importance of landing at ASE, most likely heightened the pressure on the flight crew. According to the charter customer's business assistant, his employer became "irate" when he was informed about the possible diversion to an alternate airport. The business assistant also stated that he was told to call Avjet and emphasize that the airplane was not going to be redirected. The Avjet charter department scheduler indicated that the captain felt that it was important to land at ASE because of the substantial amount of money that the customer spent for a dinner party.

In addition, the CVR indicated that, about 1853:57, the flight attendant escorted an unidentified male passenger to the jumpseat, which he occupied for the remainder of the flight. [ . . . ] the captain stated, "the weather's gone down they're not making it in," to which this passenger replied, "oh really." Also, when this passenger asked "are we clear?" about 1858:13, the captain responded, "not yet" and "the guy in front of us [N898R] didn't make it in either." This passenger again replied, "oh really." The CVR did not record any other comments by this passenger, except for an unintelligible comment about 1900:08 regarding the snow. However, the presence of this passenger in the cockpit, especially if it were the charter customer, most likely further heightened the pressure on the flight crew to land at ASE.

Source: NTSB Accident Brief


4

Cause

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's operation of the airplane below the minimum descent altitude without an appropriate visual reference for the runway.

Contributing to the cause of the accident were the Federal Aviation Administration's (FAA) unclear wording of the March 27, 2001, Notice to Airmen regarding the nighttime restriction for the VOR/DME-C approach to the airport and the FAA's failure to communicate this restriction to the Aspen tower; the inability of the flight crew to adequately see the mountainous terrain because of the darkness and the weather conditions; and the pressure on the captain to land from the charter customer and because of the airplane's delayed departure and the airport's nighttime landing restriction.

Source: NTSB Accident Brief

References

(Source material)

NTSB Aircraft Accident Brief, AAB-02/03, Avjet Corporation, Gulfstream III, N303GA, Aspen, Colorado, March 29, 2001.