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Thu, Jul 18, 2002

Noise Laws Contributed to Aspen Crash: NTSB

The full report of the March 29, 2001 Avjet G-III crash at Aspen (CO), in which all 18 aboard were killed, was attributed to the flight crew, with help from confusing NOTAM information; and from added stress to "get down," courtesy the local noise laws. Here's the summary, as proffered by the NTSB. The entire report can be seen at the cited website.

SUMMARY

1. The flight crew made numerous procedural errors and deviations during the final approach segment of the VOR/DME approach to Aspen (ASE).
The flight crew crossed step-down fixes below the minimum specified altitudes.

The flight crew descended below the minimum descent altitude (MDA), even though airplane maneuvers and comments on the cockpit voice recorder (CVR) indicated that neither pilot had established or maintained visual contact with the runway or its environment.

Contrary to the airplane manufacturer's procedures, the captain deployed the spoilers after the landing gear had been extended and the final landing flaps had been selected, and he set engine power to 55 percent N2 rather than 64 percent N2.

When the airplane was 1.4 miles from the runway (about 21 seconds before the accident), the captain asked, "where's it at?" but did not abandon the approach, even though he had not identified, or had lost visual contact with, the runway.

Radar data and CVR comments indicated that, until the airplane began turning to the left about 10 seconds before the accident, the flight crew probably did not have the runway or its environment in sight.

2. The crew demonstrated poor crew coordination during the accident flight. 

The captain did not discuss the instrument approach procedure, the missed approach procedure, and other required elements during his approach briefing because he expected to execute a visual approach to the airport.

The captain and the first officer did not make required instrument approach callouts, and the first officer did not call out required course, fix, and altimeter information.

The flight crew did not discuss a missed approach after receiving a third report of a missed approach to the airport and a report of deteriorating visibility in the direction of the approach course.
 
3. The flight crew was under pressure to land at ASE.
 
Because of the flight's delayed departure from Los Angeles International Airport and the landing curfew at ASE, the flight crew could attempt only one approach to the airport before having to divert to the alternate airport.

The charter customer had a strong desire to land at ASE, and his communications before and during the flight most likely heightened the pressure on the flight crew.

The presence of a passenger on the jumpseat, especially if it were the charter customer, most likely further heightened the pressure on the flight crew to land at ASE.
 
4. Darkness, reduced visibility, and light snow showers near the airport at the time of the accident significantly degraded the flight crew's ability to see and safely avoid terrain.

5. The March 27, 2001, Notice to Airmen (NOTAM) regarding the nighttime restriction on the VOR/DME-C approach was vaguely worded and ineffectively distributed.

Click to Enlarge


The NOTAM stated, "circling NA [not authorized] at night," but the intended meaning of the NOTAM was to prohibit the entire instrument approach procedure at night. Pilots might have inferred that an approach without a circle-to-land maneuver to runway 15 was still authorized.

If the FAA had worded the first NOTAM more clearly, it might have made more of an impression on the first officer when he received the preflight briefing from the Automated Flight Service Station and might have affected the conduct of the flight.

The local controller could not notify the flight crew of the NOTAM because the Denver Center had not sent a copy to the ASE tower.

PROBABLE 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.

FMI: www.ntsb.gov/Publictn/2002/AAB0203.htm

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