FLIGHT SAFETY F O U N D AT I O N

Accident Prevention
Vol. 59 No. 11 For Everyone Concerned With the Safety of Flight November 2002

Reduced Visibility, Mountainous Terrain

Cited in Gulfstream III CFIT at Aspen
Darkness increased and weather conditions deteriorated as the pilots continued
a nonprecision instrument approach below minimums without adequate visual
references at the Aspen (Colorado, U.S.) airport. A delayed departure, a nighttime
landing curfew and pressure from the charter customer to land were factors
cited in the controlled-flight-into-terrain (CFIT) accident.

FSF Editorial Staff

About 1901 local time on March 29, 2001, a VOR/DME-C [very-high-frequency omnidirectional
Gulfstream Aerospace Gulfstream III operated by radio/distance-measuring equipment] approach to the
Avjet Corp. struck terrain approximately 2,400 feet airport and the FAA’s failure to communicate this
(732 meters) from the runway threshold during a restriction to the Aspen [air traffic control] tower
nonprecision instrument approach in instrument [ATCT];
meteorological conditions (IMC) at Aspen–Pitkin
County (Colorado, U.S.) Airport. The two pilots, the • “The inability of the flight crew to adequately see
flight attendant and the 15 passengers were killed. the mountainous terrain because of the darkness
The airplane was destroyed. and the weather conditions; [and,]

The U.S. National Transportation Safety Board • “The pressure on the captain to land from the
(NTSB) said, in its final report, that the probable charter customer and because of the airplane’s
cause of the accident was “the flight crew’s operation delayed departure and the airport’s nighttime
of the airplane below the minimum descent altitude [MDA] landing restriction.”
without an appropriate visual reference for the runway.”
The captain, 44, held an airline transport pilot (ATP) certificate
NTSB said that factors contributing to the accident were: and had 9,900 flight hours, including 1,475 flight hours in
type. He was hired by Avjet in October 2000.
• “The [U.S.] Federal Aviation Administration’s (FAA)
unclear wording of [a] March 27, 2001, notice to airmen The report said that in January 1999, the captain was involved
[NOTAM] regarding the nighttime restriction for the in an incident.
 “The captain was landing a Gulfstream 1159-series airplane hours as a first officer in type. He was hired by Avjet in
at Chino, California, but the airplane departed the end of the November 2000.
runway and went 150 feet [46 meters] into the paved overrun
area,” the report said. “No action was taken [by FAA] against The report said that in May 1998, the first officer failed his
the captain.” first check ride for an ATP certificate because of inadequate
performance of VOR approaches and circling approaches; he
The first officer, 38, held an ATP certificate and a Gulfstream passed his second check ride for an ATP certificate in June
III type rating, and had 5,500 flight hours, including 913 flight 1998.

“On March 25, 1999, the first officer was performing a

[Gulfstream III] simulator competency check ride, during
which time it was determined that he needed additional training
to gain proficiency in normal takeoff, takeoff with engine
failure and nonprecision approaches,” the report said.

The captain and the first officer had been flying together for
five months and had conducted two flights to Aspen in daylight
conditions.

“According to Avjet’s director of operations, the company

considered [Aspen] to be a special airport,” the report said.
“He explained that, for operations into special airports, the
charter manager would discuss the flight crew’s qualifications
with upper managers and might not assign a captain to an
airport with which he/she was not familiar.”

At the time of the accident, Avjet had 55 pilots and four check
airmen in full-time employment. The company’s U.S. Federal
Aviation Regulations (FARs) Part 135 certificate [for on-
demand operations] listed 18 aircraft, including 15 Gulfstream
aircraft.

The accident aircraft was manufactured in 1980 and was

exported from the United States to Ivory Coast. In 1988, the
aircraft was substantially damaged when it struck a ditch while
being landed on a closed runway in Africa. The aircraft was
repaired by the manufacturer and returned to service in the
United States in 1989.

Gulfstream III At the time of the accident, the aircraft had accumulated 7,266
flight hours and 3,507 cycles (takeoffs and landings). The
The Grumman American (now Gulfstream Aerospace)
Gulfstream III long-range executive transport first flew in 1979.
aircraft’s registration number was N303GA.
Compared to its predecessor, the Gulfstream II, the aircraft
has a longer fuselage, more fuel capacity and a redesigned The aircraft was equipped with a Collins FPA-80 flight profile
wing, with extended-chord leading edges and winglets. advisory system, which calls out deviations from the selected
The aircraft accommodates two flight crewmembers and up altitude and radio altitude every 100 feet from 1,000 feet above
to 19 passengers. Maximum fuel capacity is 28,300 pounds ground level (AGL) to 100 feet AGL, and an AlliedSignal [now
(12,837 kilograms). Maximum takeoff weight is 69,700 Honeywell] Mark VI ground-proximity warning system
pounds (31,616 kilograms). Maximum landing weight is
58,500 pounds (28,536 kilograms). (GPWS), which calls out excessive descent rate, excessive
closure rate with terrain, excessive bank angle, insufficient
Each of the two Rolls-Royce Spey 511-8 turbofan engines terrain clearance and radio altitude at 500 feet AGL and at 200
produces 11,400 pounds static thrust (50.7 kilonewtons).
Maximum cruising speed is Mach 0.85. Long-range cruising feet AGL.
speed is Mach 0.77. Maximum operating altitude is 45,000
feet. Range is 4,100 nautical miles (7,593 kilometers). Stall The captain and the first officer reported for duty at the Avjet
speed at maximum landing weight is 105 knots.♦ facility at Burbank–Glendale–Pasadena (California) Airport
Source: Jane’s All the World’s Aircraft at 1300 Mountain Standard Time (Aspen local time, which is
one hour later than local time in California). The captain used

2 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002

 a personal computer to obtain weather information and
discussed the Aspen weather conditions with an Avjet charter Airborne View of Final Approach to
scheduler. Runway 15, Aspen–Pitkin County
(Colorado, U.S.) Airport, March 29, 2001
About one hour before reporting for duty, the first officer
obtained a briefing from a specialist at the Hawthorne
(California) Automated Flight Service Station (AFSS). The
specialist discussed three AIRMETs (airman’s meteorological
information advisories) with the first officer. The AIRMETs
advised of occasional mountain obscuration by clouds and
precipitation, occasional moderate turbulence below 15,000
feet and occasional moderate rime icing or mixed icing in
clouds and in precipitation above the freezing level.

A weather observation transmitted at 1141 by the automated

surface observing system (ASOS) at Aspen indicated that the
airport had seven statute miles (11 kilometers) visibility in
light snow, a few clouds at 1,100 feet, scattered clouds at 1,600
feet and an overcast ceiling at 3,000 feet.

“The AFSS specialist informed the first officer that the

visibility reported in this observation had recently increased Source: U.S. National Transportation Safety Board
from one mile [two kilometers] in heavier snow showers,” the
report said. Figure 1
The forecast for Aspen until 1900 was for visibilities greater
than six statute miles (10 kilometers), scattered clouds at 3,000 “The flight inspection crew [recommended to FAA] that
feet and a broken ceiling at 5,000 feet. The forecast said that circling should not be allowed at night because areas of
temporary conditions would include three miles (five unlighted terrain conflicted with traffic patterns and circling
kilometers) visibility in light snow showers, a broken ceiling descent maneuvers near the airport,” the report said.
at 2,500 feet and an overcast at 5,000 feet.
On March 27, 2001, FAA issued a NOTAM for the VOR/
The AFSS specialist also told the first officer that the Aspen DME-C approach that stated “circling NA [not authorized] at
VOR/DME-C approach circling minimums were no longer night.” The report said that “because of human error,” a flight
authorized at night. data communications specialist at the Denver (Colorado) Air
Route Traffic Control Center did not send the NOTAM to the
The Aspen airport, also known as Sardy Field, is at an elevation Aspen ATCT.
of 7,815 feet and is surrounded by higher terrain (see Figure 1).
The VOR/DME-C approach procedure includes only circling The report said that the NOTAM was vaguely worded.
approach minimums; straight-in approach minimums are not
included because a straight-in approach would require a “The NOTAM was intended to mean that the instrument
descent gradient of 700 feet per nautical mile between the final approach procedure was no longer authorized at night,
approach fix (FAF) and the runway threshold crossing height because only circling minimums were authorized for that
(see Figure 2, page 4). Among FAA’s requirements for straight- procedure,” the report said. “Thus, the NOTAM was vaguely
in approach procedures is a maximum descent gradient of 400 worded because pilots could infer that [conducting] an
feet per nautical mile between the FAF and the threshold approach without a circle-to-land maneuver to Runway 15
crossing height. was still authorized.”

“When the [Aspen] VOR/DME-C approach was first On March 30, 2001, FAA revised the NOTAM to state
established in December 1988, the procedure was not “procedure NA at night.”
authorized at night,” the report said. “The night restriction on
the approach was removed in October 1994 because of The accident aircraft had been chartered by a client who was
complaints from user groups.” hosting a party in Aspen. The itinerary was for the crew to
reposition the aircraft from Burbank to Los Angeles
On March 21, 2001, an FAA flight-inspection crew conducted (California) International Airport, pick up the charter client
a flight check of a proposed GPS (global positioning system) and the other passengers, fly the passengers to Aspen and then
approach to Runway 15. reposition the aircraft to Burbank.

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002 3

 VOR/DME-C Approach Procedure, Aspen–Pitkin County (Colorado, U.S.) Airport,
March 29, 2001

Source: U.S. Department of Transportation

Figure 2

4 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002

 The crew departed from Burbank at 1538 and landed the The crew conducted the “Descent” checklist while flying the
Gulfstream at Los Angeles at 1549. The scheduled departure aircraft from cruise altitude to Flight Level 210. When the
time from Los Angeles was 1630, and estimated arrival time first officer called for the approach briefing, the captain said,
in Aspen was 1805 — 53 minutes before a nighttime landing “We’re probably going to make it a visual [approach]. If we
curfew began at the Aspen airport for aircraft that do not meet don’t get the airport … we’ll go ahead and shoot that
FAA Stage 3 noise criteria. (The Gulfstream III does not meet [instrument] approach. … We’re not going to have a bunch of
FAA Stage 3 noise criteria; the aircraft is classified by FAA as extra gas, so we only get to shoot it once, and then we’re going
a Stage 2 airplane.) to Rifle.”

At 1630, an Avjet flight scheduler told the charter client’s The report said that the captain’s approach briefing did not
business assistant that the passengers were not at the airport include several items required by the Avjet Operations Manual,
and that the aircraft would have to depart from Los Angeles such as the instrument approach procedure and the missed
by 1655 to fly to Aspen; a later departure would mean that the approach procedure.
crew would have to fly the passengers to Rifle, Colorado, the
alternate airport included on the crew’s instrument flight rules “Thus, the flight crew was not adequately prepared to perform
(IFR) flight plan. [The Rifle airport — Garfield County [Aspen’s] instrument [approach procedure] and missed
Regional — is approximately 54 nautical miles (100 approach procedure,” the report said. “In addition, Avjet’s
kilometers) west-northwest of Aspen.] manual indicates that the captain was to brief the airplane’s
configuration and approach speed, [FAF] altitude, [MDA],
(The report said that the 1655 time limit for departure from visual descent point, circling maneuver, runway information
Los Angeles provided sufficient time for the crew to land at and abnormal conditions.”
Aspen, deplane the passengers, refuel and depart from Aspen
before the curfew began. A later departure would necessitate At 1839, the first officer listened to the Aspen automated
an overnight stay at Aspen, and the charges for the overnight terminal information service (ATIS) radio broadcast. The
stay would be billed to the charter client.) information was based on a weather observation at 1753 that
included surface winds from 030 degrees at four knots, 10
“The business assistant stated that when he told his employer statute miles (16 kilometers) visibility, scattered clouds at 2,000
about the possibility that the flight might have to divert, his feet AGL, broken ceilings at 5,500 feet AGL and at 9,000 feet
employer became ‘irate,’” the report said. “He [said that] he AGL, temperature 2 degrees Celsius (36 degrees Fahrenheit)
was told to call Avjet and tell the company that the airplane and dew point −3 degrees Celsius (27 degrees Fahrenheit).
was not going to be redirected. Specifically, he was told to say
that his employer had flown into [Aspen] at night and was The ATIS said that pilots could expect to conduct the VOR/
going to do it again. The business assistant stated that he called DME-C approach and that landing operations were being
Avjet to express his employer’s displeasure about the conducted on Runway 15 and takeoffs were being conducted
possibility of not landing in [Aspen].” on Runway 33. (The runway is 7,006 feet [2,137 meters] long,
100 feet [31 meters] wide and has medium-intensity lights.)
The report said that postaccident interviews with Avjet pilots
indicated that “the company would have placed no pressure The ATIS said that MSAW (minimum safe altitude warning)
on the captain to land at [Aspen].” services were not available from air traffic control (ATC)
because of the mountainous terrain.
The aircraft departed from Los Angeles at 1711 — 41 minutes
later than scheduled. The estimated time of arrival at Aspen The report said that Aspen does not have MSAW because of
was 1846 — 12 minutes before the curfew began. The captain “the high number of false alarms that would be created by the
was the pilot flying. high terrain surrounding [the airport].”

The report said that the cockpit voice recorder (CVR) transcript The first officer read back the wind conditions, visibility, cloud
indicates that the pilots were aware of the curfew. bases and temperatures to the captain.

At 1831, the captain said, “Well, there’s the edge of night right At 1844, the crew heard the crew of a Canadair Challenger
here.” request clearance from Aspen Approach Control to conduct
another instrument approach.
The first officer said, “What time is official sunset?”
The first officer told the captain, “I hope he’s doing practice
“Six twenty-eight,” the captain said. “So, we get thirty minutes approaches.”
after sunset. So, six fifty-eight … about … seven o’clock.”
The captain then asked the approach controller whether the
“Seven is good enough, yeah,” the first officer said. Challenger crew was conducting practice approaches or had

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002 5

 conducted a missed approach because they were unable to visual contact with the airport when their aircraft was at 10,400
continue the approach to landing. feet and were conducting a straight-in approach.

The controller said, “He actually went missed. … We saw him, The first officer said, “Ah, that’s good.”
though, at 10,400 [feet]. I [have] two other aircraft on approach
in front of you.” The controller then told the crew to fly a The captain told the controller, “Yeah, from where Golf Alpha
heading of 360 degrees for sequencing for the instrument is, I can almost see up the canyon … but I don’t know the
approach. terrain well enough or I’d take the visual [i.e., conduct a visual
approach].”
The captain asked the first officer if he could see a highway
that parallels the extended centerline of Runway 15. The first officer told the captain, “Could do a contact
[approach], but … I don’t know. Probably, we could not.”
“Where’s that highway?” the captain said. “Can we get down
in there?” At 1848, the controller told the crew to descend to 17,000
feet.
“I’m looking,” the first officer said. “I’m looking. … No.”
The captain said, “There’s the highway right there. … Can
The controller told the crew to descend to Flight Level 190 you see up there yet at all?” After the first officer said no, the
after reducing airspeed to 210 knots. The first officer read back captain said, “Can you see the highway directly down there?”
the instruction to the controller and then told the captain, “One
niner zero.” “No,” the first officer said. “It’s clouds over here. … I don’t
see it.”
The crew resumed their discussion of outside visual references.
“But it’s right there,” the captain said. He then told the flight
“Can’t really see up there, can [you]?” the captain said. attendant again that if they missed the approach to Aspen, they
would have to fly to Rifle because “it’s too late in the evening
“Nope, not really,” the first officer said. “I see a river, but I to come around” for another approach to Aspen.
don’t see [anything] else.”
At 1851, the captain told the first officer, “See, it’s right over
At 1846, the CVR recorded a comment by the flight attendant. there. Look. … Look, it’s a hundred and forty-five degrees, so
“Are you scared?” she said. it’s right back under those clouds.”

“Well, [I am] hoping we make it,” the captain said. “Somebody The first officer said, “Cannot see it. I saw the lights over there,
just missed.” but must be something else.”

“I don’t want to hear that,” the flight attendant said. “Why did The controller told the crew to turn the aircraft to a heading of
you tell me? Why didn’t you say no I’m not scared?” 050 degrees. About one minute later, the controller told the
crew to turn the aircraft to a heading of 140 degrees to intercept
“Well, I’m not scared,” the captain said. the final approach course and to maintain 16,000 feet.

The first officer said, “I’m not scared. [We] just cannot make The controller then told all flight crews monitoring the radio
it.” frequency that the “last aircraft [to conduct the instrument
approach] went missed.”
“Yeah, we don’t have enough gas to go hanging around,” the
captain said. “I mean, we’re [going to] have [enough fuel for The first officer told the captain, “That’s … not … good.”
one approach] and then we [have to] go to Rifle.”
At 1853, the flight attendant asked the crew if a passenger
The aircraft had 12,450 pounds (5,647 kilograms) of fuel when could occupy the cockpit jump seat. About the same time, the
it departed from Los Angeles. The report said that this quantity controller told the crew to “maintain slowest practical speed
was more fuel than is required to comply with FARs Part for sequence.” The CVR recorded no reply from the crew to
135.223, which requires that an aircraft carry enough fuel the flight attendant’s question.
during an IFR flight to complete the flight to the intended
destination airport, fly from that airport to the alternate airport At 1854, the flight attendant told the passenger to ensure that
and fly thereafter for 45 minutes at normal cruising speed. his seat belt was fastened. The report said that the presence of
this passenger in the cockpit, especially if the passenger was
At 1847, the controller told all flight crews monitoring the the charter client, increased the pressure on the flight crew to
radio frequency that a Cessna Citation crew had established land at Aspen.

6 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002

 At 1855, a Challenger crew told the controller that they were the active runway in sight and have sufficient time to
conducting a missed approach. make a normal approach for landing. Under such
conditions and when ATC has cleared them for landing
“The weather’s gone down,” the captain said. “They’re not on that runway, pilots are not expected to circle even
making it in.” though only circling minimums are published. If they
desire to circle, they should advise ATC.
The CVR recorded an unidentified male voice saying, “Oh,
really.” The report said that about the time the crew was cleared to
land on Runway 15, the aircraft flew over the Red Table VOR
At 1856, the controller told the crew that their aircraft was at 14,000 feet and at 160 knots (see Figure 3, page 8).
five nautical miles (nine kilometers) from the Red Table VOR
(the initial approach fix) and to cross the VOR at or above The captain asked the first officer where they could begin the
14,000 feet. The controller then cleared the crew to conduct descent from 12,700 feet. The first officer said “three DME
the VOR/DME-C approach. [three nautical miles from the Red Table VOR].”

“Here we go,” the captain said. “OK, descending to one four At 1858, the aircraft flew over the three-DME step-down fix
thousand.” at 12,700 feet and 150 knots. About this time, the controller
asked the Challenger crew if they had the airport in sight. The
“After [the] VOR, you are cleared to twelve thousand seven Challenger crew said that they did not have the airport in sight
hundred [feet],” the first officer said. and were conducting a go-around.

The report said that the cloud tops were at The CVR then recorded an unidentified
about 16,000 feet and that “after descending male voice asking, “Are we clear?”
through this altitude, the airplane was in and The report said that
out of the clouds.” “[No,] not yet,” the captain said. “The guy
the cloud tops were at in front of us didn’t make it either.”
The controller said, “Attention all aircraft,
[ATIS] information India is current.
about 16,000 feet and “Oh, really,” the unidentified male said.
Remarks … visibility north two [statute that “after descending
miles (three kilometers)].” The captain then asked the first officer for
through this altitude, the minimum altitude after the three-DME
ATIS information India said that visibility step-down fix. The first officer said that they
at the airport was 10 statute miles. The
the airplane was in and could maintain 12,200 feet until the six-
VOR/DME-C approach procedure required out of the clouds.” DME step-down fix.
a minimum visibility of three statute miles
(five kilometers) for Category C aircraft “Twelve two to six,” the captain said.
(i.e., aircraft with approach speeds greater than 121 knots but
less than 141 knots). The report said that the Gulfstream III is The aircraft was at 12,100 feet at 1859 when it flew over the
a Category C aircraft. six-DME step-down fix, which is the FAF (ALLIX). Calibrated
airspeed was approximately 125 knots; the crew had selected
The approach controller told the crew to establish radio 123 knots as their landing reference speed (VREF).
communication with the Aspen ATCT local controller.
The captain said, “OK, next altitude is?” The first officer said
At 1857, the local controller told the crew that they 10,400 feet. The captain then told the first officer to extend
were following a Challenger that was two nautical miles the landing gear and the landing flaps.
from the runway, that the surface winds were from 240
degrees at five knots and that they were cleared to land on About this time, the unidentified male said “snow.”
Runway 15.
A few seconds later, the captain said, “OK, I’m breaking out.”
The report said that pilots are not prohibited from conducting He then asked the controller if the runway lights were “all the
a straight-in landing after conducting an instrument approach way up.”
for which only circling minimums are published. Paragraph
5-4-18d of the FAA Aeronautical Information Manual states The controller said, “Affirmative, they’re on high.”
the following:
At 1900:30, the first officer told the captain that they could
The fact that a straight-in minimum is not published does descend to 10,200 feet, which was the MDA and was 2,385
not preclude pilots from landing straight-in if they have feet above airport elevation.

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002 7

 Gulfstream III Flight Path, Aspen–Pitkin County (Colorado, U.S.) Airport,
March 29, 2001

1900:54 TWR "Gulfstream three Golf Alpha cleared visu Roger."

14,000

1900:49 TWR "...you have the runway in sight?"

1858:04 RDO "one five cleared
13,000

to land three golf alpha"

D11.0
MAP
12,000

1901:13 HOT-2 "...yeah to the right is good"

Red

Altitude (feet)
D 3.0
Table ALLIX
VOR D6.0
11,000

1901:36 HOT- 1 "...where’s it at?"

MDA
10,000

1900:52 RDO "Runway in

sight three Golf Alpha"
9,000

D 9.5
8,000

12 10 8 6 4 2 0
North Range (nautical miles)

Times are coordinated universal time.

D = Distance in nautical miles from Red Table VOR HOT-1 = Statement by captain HOT-2 = Statement by first officer
MAP = Missed approach point MDA = Minimum descent altitude RDO = Radio transmission by Gulfstream III crew
TWR = Radio transmission by Aspen Tower local controller VOR = Very-high-frequency omnidirectional radio

Source: U.S. National Transportation Safety Board

Figure 3

“Ten thousand two hundred?” the captain said. have meant that the first officer had the highway in sight or
that he was repeating the captain’s words while looking for
“Ten thousand two hundred, to eleven DME,” the first officer the highway.
said. The 11-DME fix is the missed approach point (MAP).
At 1900:49, the controller asked the crew if they had the runway
After flying over ALLIX at 12,100 feet, the crew flew the in sight.
aircraft at 2,200 feet per minute to 10,100 feet — about 300
feet below the minimum specified altitude for the 9.5-DME “In postaccident interviews, controllers at the ATCT indicated
step-down fix. The crew flew the aircraft in level flight for that when they observe an airplane’s altitude about 200 feet
about 10 seconds and then began to descend again at 2,200 lower than the published altitude (to account for altimeter
feet per minute. [error] or transponder error), they ask the pilot whether the
runway is in sight,” the report said. “If the pilot does not
“At that point, the airplane’s heading increased about 15 report the runway in sight, the controller issues a low-altitude
degrees [from 168 degrees to 183 degrees] as the airplane alert and may issue missed approach instructions.”
turned slightly to the right,” the report said. (The final approach
course is 164 degrees.) The controller told investigators that she had observed the
aircraft descend below 10,400 feet before reaching the 9.5-
At 1900:43, the captain asked the first officer if he could see DME step-down fix.
the runway. The first officer’s reply was unintelligible. The
captain asked him if he could see the highway. The first officer Before responding to the controller, the first officer told the
said “see highway.” The report said that this statement could captain “affirmative.”

8 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002

 “Yes, now, yeah, we do,” the captain said. The captain said, “Where’s it at?”

The first officer then told the controller that they had the runway The report said that this statement indicates that the captain
in sight. “had not identified or had lost visual contact with the runway.
At this point, the captain should have abandoned the approach,
At this time, the crew would have had to turn left to align the especially because the airplane was close to the ground in
aircraft’s flight path with the runway; however, radar data mountainous terrain.”
showed that the aircraft turned slightly right. The report said
that the crew “probably did not have the runway in sight or At 1901:38, the FPA called out “seven hundred.”
had it in sight only briefly.”
At 1901:41, the FPA called out “six hundred.”
At 1900:56, the CVR recorded a sound similar to decreasing
engine speed. The report said that the captain reduced engine At 1901:42, the first officer said, “To the right.”
speed to 55 percent N2 and that the Gulfstream III Flight
Manual says that the power setting should be maintained at “To the right,” the captain said. At this time, the aircraft was at
64 percent N2 or higher on final approach to meet FAA go- 8,100 feet and was 1.2 nautical miles (2.2 kilometers) from
around performance requirements.1 the runway.

At 1901:00, the aircraft was flown over the 9.5-DME step- At 1901:45, the FPA and the GPWS called out “five hundred.”
down fix at 9,500 feet — 900 feet below the minimum specified At this time, the aircraft’s heading was 200 degrees.
altitude and 700 feet below MDA. Airspeed was 125 knots.
The first officer told the captain that indicated airspeed was
At 1901:12, the first officer said, “To the right is good.” “V-ref plus five.”

The report said, “It is not apparent what the first officer could Recorded ATC radar data indicate that the aircraft began a left
see from the cockpit when he made his statement because turn about 1901:47. The GPWS then called out “sink rate”
the runway would have been to the left of the nose of the because the aircraft’s rate of descent exceeded a predetermined
airplane.” threshold.

The captain did not verbally acknowledge the first officer’s At this time, the aircraft stopped turning right and began turning
statement and did not turn right. left with an initial bank angle of about 10 degrees. The report
said that this is the “first clear indication” that the captain might
At 1901:21, the CVR recorded a sound similar to the aircraft’s have seen the runway after the aircraft descended below MDA.
configuration alarm; the sound continued for nine seconds.
At 1901:48, the FPS called out “four hundred.”
The report said, “This warning indicated that the captain had
deployed the spoilers [speed brakes] after the landing gear had At 1901:49, the aircraft was descending at 900 feet per minute
been extended and the final landing flaps had been selected.” through 8,000 feet and was 0.9 nautical mile (1.7 kilometers)
from the runway. The aircraft’s left bank angle began to
The flight manual says that speed brakes must not be extended increase.
with flaps at 39 degrees (landing configuration) or with landing
gear extended. At 1901:51.8, the GPWS called out “sink rate.”

The report said that the captain likely had reduced power to The aircraft flew over a riverbed, and the terrain elevation
55 percent N2 and extended the speed brakes “to get below the decreased 140 feet. The FPA again called out “four hundred”
snow showers and visually acquire the runway.” at 1901:52.3.

At 1901:28, the FPA called out “1,000 [feet].” At 1901:52.7, the first officer said “plus ten.” At this time, the
CVR began to record an “unidentified rumbling noise”; the
At 1901:31, the FPA called out “nine hundred.” noise continued until the end of the recording. The report said
that the noise was similar to a post-accident recording of the
At 1901:34, the FPA called out “eight hundred.” At this time, sound of activation of the stick shaker (stall-warning) system
the aircraft, which was on a heading of 185 degrees, began to in a similar Gulfstream III.
turn right.
Between 1901:52 and 1901:57, the accident aircraft’s airspeed
At 1901:36, the aircraft was flown at 8,300 feet over the MAP varied between 120 knots and 127 knots. The left bank
— 1,900 feet below MDA. increased to 40 degrees.

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002 9

 “At 40 degrees of bank and the airplane’s weight at the time of airport had decreased to 1.75 statute miles (2.82 kilometers)
the accident [approximately 50,033 pounds (22,695 in light snow.
kilograms)], the stall speed was about 134 knots,” the report
said. About the time of the accident, the Rifle ASOS indicated that
the sky was clear below 12,000 feet and that visibility was 10
At 1901:53.5, the CVR recorded a sound similar to increased statute miles.
engine speed. A sound-spectrum analysis of the recording
indicated that engine power was increased to maximum at this On April 10, 2001, the FAA flight standards district
time. office in Van Nuys, California, revised the operations
specifications for Avjet and for 11 other turbojet-airplane
As the airplane flew over rising terrain in the riverbed at operators in its jurisdiction to specify that a ceiling of at
1901:53.7, the FPA called out “three hundred.” About one least 4,000 feet and visibility of at least five statute miles
second later, the FPA and the GPWS called out “two hundred.” (eight kilometers) are required to conduct the VOR/DME-C
approach at Aspen.
At 1901:57.2, the GPWS called out “bank angle.” The aircraft
was banked more than 40 degrees left at this time. On the same day, Avjet issued a memorandum to its flight
crews and flight schedulers prohibiting operations between
At 1901:57.9, the CVR recorded the sound of a grunt; it was sunset and sunrise at the Aspen airport and at three other
the last sound recorded by the CVR. airports located in mountainous terrain: Eagle, Colorado;
Telluride, Colorado; and Hailey, Idaho.
The local controller told investigators that about one minute
after she asked the crew if they had the runway in sight, she The accident occurred 34 minutes after official sunset, which
observed the aircraft “come out of the snow, pointed at Shale the report defined as when “the center of the sun is 0.8333
[Bluffs],” which is northwest of the airport, and rapidly enter degrees below the horizon and its top edge is at the horizon.”
a steep left bank. Official sunset was 1828. The report said, however, that the
sun set below the mountainous terrain near Aspen about 25
“The local controller said that the airplane appeared low and minutes before official sunset.
to the right of the centerline,” the report said. “She indicated
that the pilot apparently ‘got the runway and turned toward it.’ “The shadow for the ridge immediately to the west of the
She noted that the airplane looked as if it were accelerating, accident site would have crossed the site 79 minutes earlier
with its lights pointed directly at the tower, and that the airplane than official sunset,” the report said. “All eyewitnesses to the
was rolling rapidly to its left.” accident reported that lighting conditions were very dark at
the time of the crash. … Because of these low light conditions,
The report said that the captain might have made the steep left the pilot of N303GA most likely would not have been able to
turn to line up with the runway, to line up with the highway or see the unlighted terrain while maneuvering to land.”
to avoid terrain.
The report said that the Flight Safety Foundation CFIT
About five seconds after the controller observed the aircraft Checklist includes limited lighting, a nonprecision approach
emerge from the snow shower, she observed an explosion and and mountainous terrain as high-risk factors for controlled
activated an emergency siren to alert the airport’s aircraft rescue flight into terrain (CFIT).2
and fire fighting unit.
“Investigators determined that the combined effects of the
The aircraft was banked 49 degrees left when it struck terrain surrounding terrain’s high elevation and weather conditions
300 feet (92 meters) right of the extended runway centerline created twilight [conditions] and nighttime conditions much
and 100 feet above runway threshold elevation. earlier than would have occurred in non-mountainous terrain
and in clear weather,” the report said.
“The impact subjected the airplane to severe accordion-type
crushing, causing components to separate and structure to Based on this finding, NTSB on April 15, 2002, made the
fracture,” the report said. following recommendation (no. A-02-08) to FAA:

Autopsies of the captain, the first officer and the flight attendant Revise any restrictions and prohibitions that currently
indicated that they died from “multiple blunt-force injuries.” reference or address “night” or “nighttime” flight
The Pitkin County coroner said that the cause of the deaths of operations in mountainous terrain so that those
the passengers was “massive blunt-force trauma.” restrictions and prohibitions account for the entire period
of insufficient ambient light conditions, and ensure that
Ten minutes after the accident occurred, the ASOS transmitted it is clear to flight crews when such restrictions and
a special weather observation indicating that visibility at the prohibitions apply.

10 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002

 [In a letter dated June 24, 2002, FAA responded, in part, to Based on this finding, NTSB on June 13, 2002, made the
NTSB recommendation A-02-08, as follows: following recommendation (no. A-02-12) to FAA:

To address this safety recommendation, the FAA will Revise [FARs] Part 135 to require on-demand charter
establish flight inspection policy for evaluating the effect operators that conduct operations with aircraft requiring
of terrain on [instrument approach] minima or procedures two or more pilots to establish [an FAA-approved CRM]
limited to daylight only. The FAA will develop a training program for their flight crews in accordance with
subtractive factor to sunset and an additive factor to [FARs] Part 121.
sunrise to account for loss of light prior to the predicted
sunset and after the predicted sunrise. [In a letter dated Aug. 8, 2002, FAA responded, in part, to
NTSB recommendation A-02-12 as follows:
Potential methods of assessing these factors include on-
site evaluation (on the ground and in flight), local There is no regulatory initiative underway at this time to
experience gained from official sources (like air traffic revise [FARs] Part 135. However, when a regulatory
control facilities and local and state police agencies) and initiative is considered, CRM training for [FARs] Part
computer modeling. 135 on-demand charter operators with two or more pilots
will be included.
The intent of this action is to provide guidance to
pilots on procedure restriction and prohibitions by In the interim, the FAA will issue a notice to its inspectors
referencing times relative to legal sunset/sunrise, like the who have oversight responsibility for [FARs] Part 135
following chart note: “Procedure NA SS − :50 through on-demand operators to remind them of the circumstances
SR + :50.”] of the accident. The notice will direct inspectors to point
out pertinent information contained in [Advisory
Another recommendation to FAA was based on a finding Circular] 120-51D [Crew Resource Management
from the accident investigation that the flight crew Training] to its operators and emphasize the importance
demonstrated inadequate crew resource management of CRM training. The inspectors will be directed to relay
(CRM). this information at the next normal contact with their
operators.]♦
The report said, “The accident flight crew exercised poor CRM
in the following ways: [FSF editorial note: “This article, except where specifically
noted, is based on U.S. National Transportation Safety Board
• “The captain did not brief the instrument [approach (NTSB) Aircraft Accident Brief DCA01MA034 (42 pages with
procedure] and missed approach procedure or any other illustrations), NTSB Safety Recommendation A-02-08 (five
required information; pages), NTSB Safety Recommendation A-02-12 (six pages)
and NTSB Factual Report DCA01MA034 (981 pages with
• “The flight crew did not make required instrument appendixes and illustrations).]
approach callouts;

• “The captain did not include the first officer in the Notes
aeronautical decision-making process; and,
1. N2 is engine high-pressure rotor speed, which is typically
• “The first officer did not question or challenge the captain displayed as a percentage of maximum revolutions per
or intervene when he placed the airplane in a potentially minute.
unsafe flying condition.”
2. Controlled flight into terrain (CFIT) occurs when an
The report said that the Avjet Training Manual included CRM airworthy aircraft under the control of the flight crew is
as a subject to be covered during initial training and recurrent flown unintentionally into terrain, obstacles or water,
training of Gulfstream pilots; nevertheless, the company was usually with no prior awareness by the crew. This type of
not required to establish an FAA-approved CRM training accident can occur during most phases of flight, but CFIT
program for its pilots. is more common during the approach-and-landing phase,
which begins when an airworthy aircraft under the control
FAA requires approved CRM training for pilots of air carriers of the flight crew descends below 5,000 feet above ground
operating under FARs Part 121 and for pilots of commuter level (AGL) with the intention to conduct an approach
airlines operating under Part 135; FAA does not require and ends when the landing is complete or the flight crew
approved CRM training for pilots of on-demand operations flies the aircraft above 5,000 feet AGL en route to another
conducted under Part 135. airport.

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • NOVEMBER 2002 11

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FLIGHT SAFETY FOUNDATION
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