Figure: Airborne view of runway 15, from NTSB Accident Brief, Figure 2

Eddie Sez:

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. 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.


Accident Report


Narrative

  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. 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.
  2. The crew demonstrated poor crew coordination during the 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.
  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. 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 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."


See Also

Pilot Psychology / Safety > Comfort > Reliability


References

Aviation Safety Network

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