Pressure on pilots a key factor in Aspen GIII crash

 - April 9, 2008, 6:10 AM

The NTSB’s recently released final report on the fatal crash of a chartered Gulfstream III, N303GA, at Aspen, Colo., on March 29 last year indicates that from the start little went right for this flight. A much later than planned departure from Los Angeles International Airport launched a race to beat an approaching curfew, ever darkening skies, deteriorating weather at the destination and a critical fuel situation.

The race was lost, with tragic results. All three crewmembers and 15 passengers were killed when the jet hit rising terrain less than half a mile short of the runway.
The NTSB’s synopsis of the events speaks clearly of the circumstances surrounding this CFIT accident. It also contains invaluable lessons for flight crews of all experience levels. With these points in mind, the Safety Board’s findings and expert opinions follow below, edited only for length and clarity.

The Safety Board determined that the probable cause of the accident was the flight crew’s operating the airplane below the MDA without visual reference to the runway. But many factors were cited as contributing to the accident: the “unclear wording” of a notam regarding a nighttime restriction of the approach to the airport; the inability of the flight crew to adequately see the mountains because of the darkness and weather conditions; pressure from the charter customers for the captain to land the airplane at Aspen and the delayed departure of the airplane from California, causing the flight to arrive in the Aspen area at just before airport’s nighttime curfew for Stage 2 jets went into effect.

The flight crew made “numerous procedural errors and deviations” during the final approach, according to the Board. Specifically, the pilots crossed several step-down fixes below the minimum specified altitudes, descended below the MDA and passed through the MAP even though airplane maneuvers and comments on the CVR indicated that neither pilot “had established or maintained visual contact with the runway or its environment.”

According to an airplane performance study conducted by the Safety Board, about two minutes before the accident the airplane leveled off at an altitude of 10,100 ft msl, 300 ft below the minimum specified altitude required for the airplane’s position at the time, about three nautical miles from touchdown. A few seconds later (about the time the captain was asking the first officer if he had a highway in sight), N303GA had descended about 200 ft below the MDA, and almost a minute before the crash and about the time the first officer responded to the Aspen Tower controller that he had the runway in sight, the jet had descended about 450 ft below the MDA.

Evidence suggested, however, that the flight crew did not actually have the runway in sight or had it in sight at that point only briefly. Specifically, the CVR did not record any previous independent indication from either flight crewmember that he had visually identified the runway. Also, the CVR did not record any further discussion throughout the rest of the flight that would be consistent with a flight crew that could see a runway.

Less than a minute before the accident, when N303GA was about 900 ft agl, the CVR recorded a configuration deviation warning that lasted for nine seconds. This warning indicated that the captain had deployed the spoilers after the landing gear had been extended and landing flaps selected in the full-down position, which is prohibited by the AFM. “It is likely that the captain deployed the spoilers on short final in an attempt to increase the airplane’s rate of descent to get below the local snow showers and visually locate the runway,” said the Safety Board.

Further, when the captain deployed the spoilers, the engine power was set to about 55 percent N2, rather than 64 percent as stated in the AFM. The higher N2 setting allows for minimum engine spool-up time in the event of a missed approach. “The deployment of the spoilers at the incorrect power setting for the final approach placed the airplane in a potentially unsafe and destabilized condition,” the Safety Board emphasized.

Some 30 sec before the accident, N303GA passed the MAP about 8,305 ft msl (485 ft agl) rather than the specified 10,200 ft msl (2,380 ft agl). According to the charter operator’s procedures, the first officer was required to call out, “Missed approach point, runway in sight,” or “Missed approach point, runway not in sight,” and the captain was required to announce his intentions. The CVR did not record any of these callouts.

About the same time as the airplane passed the MAP, the captain asked, “Where’s it at?” This statement suggested to the NTSB that the captain had not identified, or had lost visual contact with, the runway. “At this point, the captain should have abandoned the approach or the first officer should have called for a go-around, especially because the airplane was close to the ground in mountainous terrain,” said the Safety Board.

The first officer stated, “To the right,” about six seconds after the captain’s query. Even if the first officer did in fact have the runway in sight at this point, the captain, as the flying pilot, should not have been relying on the FO for directional guidance during the visual transition from the instrument approach. Radar data and CVR comments indicated that, until the airplane began turning left toward the runway about 10 sec before the accident, the pilots “probably did not have the runway or its environment in sight.”

Conversations recorded by the CVR during the last two minutes of flight suggest that the flight crew was preoccupied with looking outside the cockpit in an attempt to locate the airport visually. As a result, the captain continued flight below the MDA after failing to establish or maintain visual contact with the runway. The first officer did not challenge the captain’s actions.

‘Poor Crew Coordination’
The NTSB also said the crew demonstrated “poor crew coordination.” The captain did not discuss the approach procedure, the missed procedure and other elements required by the charter operator during his approach briefing because he expected to make a visual approach.

The cockpit crew did not make required callouts, and the first officer did not call out course, fix and altimeter information as required by the charter operator’s procedures.

Even after receiving a third report of a missed approach and a report of deteriorating visibility in the direction of the approach course (just two miles in snow showers, wind 060 deg at three knots), the crew did not discuss taking the miss. Visibility was also reduced by the growing darkness, “degrading the crew’s ability to see and avoid terrain.”

Because of the flight’s late departure from Los Angeles (about 41 min later than originally planned, due to the late arrival of passengers), the landing curfew at Aspen and fuel considerations, the flight crew indicated they could attempt only one approach to the airport before having to divert to their alternate–Rifle, 44 nm from Aspen. The pilot is heard on the CVR saying, “We don’t have enough gas to go hanging around. I mean…we can only do one [approach] and then we gotta go to Rifle. I mean we’re here but we only get to do it once because it’s too late in the evening then to come around [an apparent reference to the curfew] and the other one is…not enough fuel.”

The charter customer “had a strong desire” to land at Aspen, according to the Safety Board, and his communications before and during the flight “most likely heightened the pressure on the flight crew.” The NTSB refers to someone in the jump seat and said if it was the charter customer, “this most likely further heightened the pressure on the flight crew to get into Aspen.”

NTSB chairman Marion Blakey said, “We know from interviews that the pilot certainly had been under pressure from the charter customer, who seemed quite determined that they would land at all costs at Aspen that night. He had contacted the charter company to make known how strong his views were. He was critical of the pilot apparently before the flight took place. We do not know who sat in the jump seat, but our concern is that it may very well have been the charter customer.”

The CVR recording did indicate the presence of another person in the cockpit from time to time, but one of the last things said by that other person–“I’m gonna buckle them in”–and other references indicated that the other person may have been the flight attendant. At one point she asked the pilots if they were scared.

According to NTSB aviation safety director John Clark, “We believe from the conversations and the way the airplane was being flown that there were times that [the Safety Board was] not sure they ever had [the airport] in sight. [The crew] claimed they had it in sight, but there are times when it was clear to us that they did not have it in sight. They were looking to the right and the airport was clearly to the left.”

During the meeting in which the synopsis was released, the NTSB’s Bill English said that from the “very limited” prebrief by the captain before arriving in the Aspen area, it “appeared he was more fixated” on making a visual approach. He called the captain’s “mismanagement” of the spoilers and power “surprising.”

The captain extended the spoilers with the flaps in their full down position, which is prohibited by the AFM. He also did not maintain the required power settings for a rapid spool-up, should he have to make a go-around, English said. The NTSB staffer opined that the last chance the pilot had to remove himself from this situation was at 400 ft, when he asked, “Where’s it at?” According to English, “It’s obvious he did not have the runway in sight at that particular time. Had he made a go-around at that time, we may not be sitting here talking about it today.”

A notam issued two days before the accident was “vaguely worded and ineffectively delivered.” The notam stated, “Circling NA at night,” but the intended meaning was to entirely prohibit instrument approaches at night. The NTSB suggested that pilots might have inferred that an approach without a circle-to-land maneuver to Runway 15 was still authorized at night.

“If the FAA had worded the notam more clearly, it might have made more of an impression on the first officer when he received the preflight briefing from the FSS and might have affected the conduct of the flight.” The local controller could not re-iterate this to the flight crew, however, because Denver Center had not sent a copy to Aspen Tower. Without knowledge of the notam, the approach controller cleared the flight crew for the VOR/DME-C instrument approach procedure. On March 30, a day after the crash, the FAA issued a second notam for Aspen that explicitly banned all night instrument landings.

According to Avjet, the operator of the ill-fated GIII, the pilot had logged a total of about 9,900 hr TT, with 1,475 of them in the GIII since obtaining his type rating in January 1990. The copilot was reported to have 5,500 hr TT, with 913 in the GII and GIII. He obtained his type rating in the GIII in February last year. Toxicology testing of the two airmen produced negative results.

Avjet said the crew and this aircraft had flown “multiple trips to and from Aspen” in March.

Washington editor Paul Lowe contributed to this article.