Ntsb Report - Giii Accident / Kase

Thu Jun 20, 2002 9:09 am

This was released last week by the NTSB. I thought that some of you might appreciate the information.


FOR RELEASE: June 11, 2002 SB-02-16


Washington, D.C. -- The National Transportation Safety Board today
determined that the probable cause of an aviation accident in Aspen,
Colorado involving a Gulfstream III was the flight crew's operation of the
airplane below the minimum descent altitude without visual reference to the

Contributing to the accident was the Federal Aviation Administration's (FAA)
unclear wording of a Notice to Airmen (NOTAM) regarding the nighttime
restriction of the VOR/DME-C approach to the airport. Also cited as
contributing factors were the inability of the flight crew to adequately see
the mountain terrain because of the darkness and weather conditions, the
pressure from the charter customers for the captain to land the airplane,
and the delayed departure of the airplane from California, causing the
flight to arrive at sunset during the airport's nighttime landing

On March 29, 2001, a Gulfstream III owned by Airbourne Charter, Inc. and
operated by Avjet Corporation of Burbank, California, with 15 passengers, 2
pilots and 1 flight attendant, crashed on final approach to runway 15 at
Aspen-Pitkin County Airport (ASE). The airplane crashed into sloping
terrain about 2,400 feet short of the runway threshold. All persons aboard
the aircraft died.

The Safety Board's investigation determined the following facts: (1) the
flight crew descended below the minimum descent altitude even though the
airplane maneuvers and comments on the cockpit voice recorder indicated that
neither pilot had established nor maintained visual contact with the runway
or its environment; (2) 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;
and (3) a copy of the FAA issued NOTAM on March 20, 2001, stating "circling
not authorized at night for runway 15 at Aspen" had not been sent to the
Aspen tower. Without knowledge of the NOTAM, the approach controller
cleared the flight crew for the VOR/DME-C instrument approach procedure.

Following the accident, the FAA became concerned about potential pilot
confusion regarding the wording of the NOTAM -- specifically, that pilots
might infer that straight-in landings to runway 15 were authorized at night.
On March 30, 2001, a revised NOTAM was issued stating, "procedure not
authorized at night."

In light of the fact that in mountainous terrain night conditions can exist
prior to sunset due to the geography and ambient lighting conditions, the
Safety Board issued an emergency Safety Recommendation on April 15, 2002
asking the FAA to:

"Revise any restrictions and prohibitions that currently reference or
address 'night' or 'nighttime' flight operations in mountainous terrain so
that those restrictions and prohibitions account for the entire potential
period of darkness or insufficient ambient light conditions, and establish a
method to clearly communicate to flight crews when such restrictions and
prohibitions apply.

Following today's Board meeting, the Safety Board made the following
recommendation to the FAA:

Revise 14 Code of Federal Regulations Part 135 to require on-demand charter
operations 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.

The complete report will be available on the website in about one month.
Printed copies of the report may be purchased later this spring from the
National Technical Information Service (NTIS) (800) 553-NTIS.

Media Contact: Terry N. Williams
(202) 314-6100

Posts: 6633
Joined: Tue May 18, 1999 11:10 am

RE: Ntsb Report - Giii Accident / Kase

Thu Jun 20, 2002 9:21 am

Thats one hell of an approach, I've flown it a few times in the simulator. Not too bad as far as complexity goes, but the terrain and decent(s) make it quite interesting. Something like 4 seperate stepdowns and a final decent angle of of around 10 degrees. Very high minimums with some nasty surrounding terrain. Not exactly something I'd want to try at night even if it was legal...

Kind of interesting how the NOTAM had not been passed on to the ASE tower.

RE: Ntsb Report - Giii Accident / Kase

Thu Jun 20, 2002 10:18 am

You've got that right. We fly into Aspen several times per year and I've shot the approach "for real" about a dozen times, including once, just a few days after the accident. Of all of the airports that we go to, ASE is far and away my least favorite.

After reading this report, I am reminded of that picture of the old WWI biplane stuck in the tree. The caption reads, "Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect." My bet is that this accident will be one that is discussed in CRM training for years to come.


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