Blog #4

Here are some of my thoughts on the arrival of N303GA in Aspen. Including the error chain and some ways to better fly in the future.

Departing from Las Angeles Airport on March 29, 2001, the Gulfstream III N303GA crashed on final approach when attempting to land at Aspen-Pitkin county Airport. Crashing into sloped, mountainous terrain, the aircraft was a mere 2,400 feet away from the runway threshold at the airport of intended landing. All of the fifteen passengers, two pilots and one flight attendant were killed immediately upon impact. There were many factors that lead up to and facilitated the tragic events that happened aboard N303GA and even many more that were sewn up before the aircraft even took off. The chain of events that took place was preventable and mostly, if not entirely, related and due to human error within the cockpit and also ground facilities / services.

            The plane itself, N303GA, was at the time being operated under instrument flight rules at night and in instrument meteorological conditions. The aircraft was owned by Airbourne Charter, Inc and operated by the Avjet Corporation out of Burbank California. Operated under CFR Part 135, the aircraft for the particular, and last, flight in question was piloted by a Captain: Age 44, hired by Avjet in 2000, 9,900 total flight hours and a First Officer: Age 38, also hired in 2000, 5,500 total flight hours. Both of the pilots were familiar with the jet they were flying and had recently been to recurrent training in the aircraft. All correct and pertinent certificates were held by both pilots and there were no violations or questions as to their experience in or knowledge of the Gulfstream III.  As far as the crash indicators and investigations are concerned, there were no medical or pathological reasons for the pilots to make any errors in fight or as to why the crash happened. The pilots were well rested and completely qualified to fly the aircraft in question. Though this being said, later parts of the investigation will uncover factors in flight that heightened the stress of the pilots to a point that could have forced them into a series of bad decisions and eventually adding to the error chain.

            The flight from LAX (Las Angeles, California) to ASE (Aspen, Colorado) was intended to depart at 1630Z, though due to passengers being late to arrive at the airport the flight actually got to take off at 1711Z. The factors that were in play for the flight leaving late were that it was said in the NOTAMS for the intended airport that circling minimums were not permitted on the VOR/DME approach into ASE 30 minutes after sunset. As it were, the pilots believed that they could still utilize the approach, though just not use circling minimums. This was not what was intended by the FAA released NOTAM, which actually meant for the entire approach to be shut off at nightfall (because of its utilization of circling minimums). The wording of the NOTAM itself lends itself much to the error chain. The crew was also already in trouble on account of the late departure because the airport had a restriction for the type of aircraft not to be able to land 30 minutes after nightfall, this was on account of noise restrictions. When the aircraft arrived and began the approach it was minutes from the restriction. Before and during the flight (and also during the initial briefing), the captain made several remarks about a possible diversion to Garfield County Regional Airport in Rifle, CO. Listing this as an alternate, the captain also made remarks while on approach that because of fuel reserves there would be only one landing attempt at ASE. If the approach ended up going missed the first time then the final landing would be at Rifle, CO. Adding sharply to the stress of the pilots, specifically the captain, was the person who booked the charter from the start. Upon hearing of a possible diversion, the client being flown made numerous calls to the Avjets base saying that a diversion would not be possible and that business would be lost if one was made. Later when the pilots were commencing the approach into ASE, another customer came to the cockpit and sat in the jump seat, thus creating a distraction and adding again to the overall stress. When the pilots were starting the VOR / DME approach into ASE there were two other planes that had been commencing the same approach before them. Both of the planes went missed on their approaches and diverted. When N303GA was doing the approach the crew stayed low but did not have the chance to do a visual approach (due to neither pilots being familiar with the area). On final approach, the pilots told the controller that they had the airstrip in sight, though a lack of callouts for the runway and feet to go show that they may not have had any parts of the runway environment actually in sight. Also, even though both of the pilots allegedly did not have the runway environment in sight they still descended below the published MDA of 10,200ft for landing. When the descent below the MDA commenced, the captain engaged the spoilers while the flaps were engaged for landing and the airspeed was slow, thus increasing the aircraft descent rate to dangerous levels. When the descent below the MDA finally provided the crew with a sight picture, they saw that a left bank was needed to make the runway and the plane began a 40 degree turn. The tight turn at low altitude forced the wing to hit terrain that was unseen by the pilots due to the low visibility at the time. The plane tumbled though terrain and killed all passengers and crew upon impact.

            As far as I am personally concerned, the ultimate cause of the crash of N303GA at ASE was descent below MDA without the proper runway environment in sight. The error chain, clearly defined, I believe started on the ground before the flight even began. First, the NOTAM released regarding the circling minimums and not using the published approach plate was worded incorrectly, thus leading the pilots to believe that they could, in fact, use the plate when it was not intended for use. Second, The passengers arrived late for the flight, making the time schedule tight and a low visibility inevitable. Third, a passenger that needed to be in Aspen kept pestering the airline and ultimately the captain for a landing, no matter the safety consequences, thus adding greatly to the crew’s stress and decision making process. Fourth, proper briefings and callouts were not called by the captain or the first officer (such as the approach briefing, MDA, missed approach procedure, 1000ft to go etc.). Fifth, a passenger was allowed to sit in the jump seat during an already risky approach, thus adding again to the crew’s stress in the cockpit. Sixth, the aircraft was descended to below the Minimum Descent Altitude for the published approach (which was already not supposed to be used at that time) without the actual runway environment being in sight, thus creating an unsafe landing environment. Seventh and Finally, the aircraft’s spoilers were engaged while there was too high of a flap setting and too low of a power setting, thus creating a descent rate much too fast to make a safe landing on the runway and ultimately crashing the aircraft into the ground just 2,400ft away from the threshold.

            The actions that I have found to be in play during the entire flight and crash of the aircraft are all in sequence and create a chain that lead to the demise of the crew and passengers. Situation / Human Caused: The passengers were late to arrive, the charter holder was pressuring the crew to make a touchdown in Aspen no matter what, the crew did not brief the approach properly and also did not make correct callouts. Slips or Mistakes: Spoilers engaged with too high a flap setting and too low a power setting, the pilots decided to descend below the MDA without the airport environment in sight. Omission, commission, or substitution: The pilots omitted from their decision process that they had seen two other aircraft miss the exact same approach that their aircraft was partaking on. 

            Based on my research, I believe that there are multiple things that the government, crew, and air carrier could have done to prevent such an accident in the future. First of all: The air carrier, Avjets, could have done a much better job as far as policy creation and enforcement. I believe that letting a customer comment and have influence on a flight is extremely risky and unsafe. The customer himself had to be in a place at a certain time and kept making complaints to the captain and airline, when the airline actually headed the remarks of the customer and contacted the captain I believe they were creating an unsafe, stressful environment in the cockpit. I also believe that the company should have a policy that no persons should be able to sit in the cockpit jump seat unless they are crew. The man sitting in the jump seat also created a much more stressful environment for the crew of the aircraft. In addition to these changes, it may be helpful for more training to be done for Avjet pilots as far as briefing approaches, making the correct callouts, and clarifying what is meant by certain NOTAMS. On the government side: The government, specifically the FAA, could have done one major thing to prevent this accident in my opinion. What the government could have done was make a more easily interpreted NOTAM. The NOTAM that was filed for the airport in question showed that the VOR / DME approach plate’s circling minimums were not to be used, what the FAA had actually meant by the NOTAM was that the entire approach was not to be used at night time, the NOTAM was also not sent to the ASE tower, which of course lead to the crew using the plate and making an unsafe approach. Lastly the crew: The crew could have done many things to prevent this accident. First of all they could have made their briefings and correct callouts, secondly they could have double checked the NOTAM to clarify what they meant, third they could have simply ignored the protests of the customer and diverted to their alternate, finally they could have used spoilers, flaps and power correctly and not caused themselves to descend at the furious rate they did.

            As far as the recommendations coming from the government, they are very similar to the ones I have provided, which is likely due to their obvious nature. I believe that if my and the government suggestions were headed that the flight would not have proven unsafe and the people who died that night would still be alive today.

             In conclusion I believe that this flight was a chain of errors that could have been avoided. If at any time the crew had diverted or decided to not descend without a runway in sight then the souls aboard that doomed flight may be alive his very day. The rules and regulations are written in blood, it is our job to stay safe and make sure the blood was not spilled in vain.

-Chappy