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Fri, Jun 14, 2002

Aspen Crash Reinforces Previous NTSB Part 135 Recommendations

In the wake of its report on last year's Avjet's crash in Aspen (CO), that took 18 lives ("Aspen Crash Report Disclosed"), the NTSB has again recommended better cockpit management.
The NTSB said, in a request for FAA action released Thursday,

Pages 4-4 and 4-5 of Avjet’s Operations Manual indicate the flight crew callouts that are
required during the final approach segment of an instrument approach. The captain is
responsible for announcing his intentions after the decision height or missed approach point
(MAP). The first officer is responsible for several callouts, including the following:

  • At 1000 feet above minimums: Call “1000 to go, no flags.”
  • At 500 feet above minimums: Call “500 to go.”
  • At 100 feet above minimums: Call “Approaching minimums.”
  • At MDA (Non-precision): Call “At minimums (time) (distance) to go.”
  • At MAP (Non-precision): Call “Missed approach point, runway in sight” or “Missed approach point, runway not in sight.”

Therefore, when the airplane reached altitudes of 11,200, 10,700, and 10,300 feet,
Avjet’s Operations Manual required the first officer to call out, “1000 to go [until landing
minimums],” “500 to go,” and “approaching minimums,” respectively. However, the CVR did
not record him making any of these callouts.

Some of what the Cockpit Voice Recorder revealed showed that the crew wasn't doing things strictly "by the book," at any rate:

At 1901:36, N303GA passed the MAP about 485 feet above field elevation rather than
the specified 2,385 feet. 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. However, the CVR did not record either of these callouts or any
evidence that the captain or the first officer understood that they were flying at too low an
altitude.
About the same time as the airplane passed the MAP, 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 or the first officer should have called for a go-around, especially because the airplane was close to the ground in mountainous terrain. The first officer stated, “to the right,” about 6 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 first officer for directional guidance during the visual transition from the instrument approach to the landing.

In other words...

Conversations recorded by the CVR during the last 2 minutes of flight suggest that the
flight crew was preoccupied with looking outside the cockpit in an attempt to visually locate the airport. As a result, the captain continued flight below the authorized MDA after failing to
establish or maintain visual contact with the runway. The first officer did not challenge the
captain’s actions.

Not the first time this has been recommended

The idea that Part 135 ops are similar-enough to other for-hire operations is not a new one, at the NTSB. That was made clear in Thursday's release.

As part of a 1994 safety study, the Safety Board issued Safety Recommendation A-94-196, which recommended that the FAA “revise within 1 year the pilot training requirements for scheduled Part 135 operators such that: all pilots are provided mandatory crew resource management training that incorporates the principal components of effective CRM training.” In response to this recommendation, on December 20, 1995, the FAA issued the final rule titled, “Air Carrier and Commercial Operator Training Programs,” which established a requirement that, after March 19, 1997, 14 CFR Part 135 commuter operators that conduct scheduled operations with aircraft requiring 2 pilots or that have 10 or more passenger seats must establish, among other things, an FAA-approved CRM training program for its pilots in accordance with 14 CFR Part 121, subparts N and O.18 However, because this requirement did not extend to Part 135 on-demand charter operators, Avjet was not required to establish an FAA-approved CRM training program for its pilots.

The Avjet flight brought the point home.

The evidence from this investigation has shown that the accident flight crew exercised
poor CRM in the following ways: (1) the captain did not brief the instrument and missed
approach procedures or any other required information, (2) the flight crew did not make required instrument approach callouts, (3) the captain did not include the first officer in the aeronautical decision-making process, and (4) the first officer did not question or challenge the captain or intervene when he placed the airplane in a potentially unsafe flying condition. The Safety Board is concerned that Part 135 on-demand charter operators, such as Avjet, and other operators that conduct operations with aircraft requiring two or more pilots do not need to meet the CRM training requirements outlined for Part 135 commuter operators.

Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration:

Revise 14 Code of Federal Regulations (CFR) Part 135 to require on-demand charter operators that conduct operations with aircraft requiring two or more pilots to establish a Federal Aviation Administration-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. (A-02-12)

FMI: http://www.ntsb.gov/Recs/letters/2002/A_02_12.pdf

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