When a Gulfstream III went down at Aspen, Colo., in 2001, it was yet another pilot-error-induced controlled flight into terrain. Aviation safety analysts have pointed out the mistakes made by the flight crew, but underlying this is a failure to require cockpit resource management training for jet charter operators.
May 7, 2003
On March 29, 2001, about 1902 Mountain Standard Time (MST), a Gulfstream III, N303GA, operated by Avjet Corporation, crashed into sloping terrain about 2400 feet short of Runway 15 at Aspen-Pitkin County Airport Sardy Field (ASE), Aspen, Colo. The three crewmembers and all 15 passengers were killed, and the airplane was destroyed. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand passenger charter flight from Los Angeles International Airport (LAX), Los Angeles, Calif., to ASE.
First, read the reprint of the NTSB safety recommendation. It was dated June 13, 2002, addressed to Jane Garvey (FAA administrator at the time) from Marion Blakey (NTSB chairman at the time). Then return to this article for an analysis of the accident and the safety recommendation.
On the basis of "the straw that broke the camel's back," the National Transportation Safety Board has finally reached a plateau in the form of operation-specific urgency. The NTSB wants the FAA to require Part 135 on-demand charter operators that conduct operations with aircraft requiring two or more pilots to establish an FAA-approved Crew Resource Management (CRM) training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. In light of the tragic Gulfstream III accident in Aspen in 2001, where there was such a breakdown in communications, responsibilities, and procedures between the crew members, it was plainly obvious that Crew Resource Management training probably would have prevented the crash.
Part 135 on-demand jet charter statistically remains the highest in accident rates per 100,00 flight hours. We cannot put the blame 100% in the CRM department, but the author believes there is a correlation between the highest accident rates and the lack of required CRM training for these operators.
To prove this point, refer to Table 1 below. This is a line-by-line comparison of accidents per 100,000 flight hours for all types of aviation operations.
Table 1: Accidents Per 100,000 Flight Hours, 1987-1998
Part 91 Fractional Business Jets
Part 91 Corporate/Professionally-Flown Business Jets
Part 121 Scheduled Air Carriers
Part 91 Corporate/Professionally-Flown Aircraft (all a/c)
Part 121 Non-Scheduled Air Carriers
Part 135 Scheduled Commuters
Part 135 On-Demand Jet Charter
Crew Resource Management, formerly known as Cockpit Resource Management, has its roots at United Air Lines, where in 1980, a formal training program was set up to concentrate on the human factor in aviation. Airlines were noticing that although pilots were technically competent, their people skills were deficient. In other words, the captain could fly a perfect ILS approach, but could not work in a synergistic environment to effectively accomplish tasks. This can create a potentially dangerous and antagonistic situation. CRM, amongst other things, teaches pilots how to improve communication, prioritize tasks, delegate authority, and monitor automated equipment. Prior to United's program, the mentality in the business was "the captain is God, and what he says goes." Thankfully, we have long thrown that thinking out the door!
All U.S. airlines are required to teach pilots CRM training as an initial course and then annually as a recurrent, or refresher, course. Although there can be no real statistical measure of the efficacy of CRM training, airline crews have come a long way in preventing accidents by utilizing the basic concepts of CRM. But this training is not required for Part 135 charter operators as of today. Prudent Part 135 operators have voluntarily incorporated CRM training in their normal pilot training events, but definitely not to the level where it should be. This training may become mandatory shortly, and it won't be a moment too soon. As you can see from our accident example in the beginning, the NTSB has had enough of "freewheeling crews" in the cockpit. Let's take a look at why CRM needs to be in the Part 135 jet cockpit now.
The Aspen, Colo., accident will be used as a "classic case" scenario in which the breakdown of flight crew procedures was a direct result of the inability of the crew to work together as a team. This is also the case that triggered the NTSB to take action and make its recommendation to the FAA.
The air charter and airline businesses are just that. Businesses. The bottom line is to make money. Making money can oftentimes come at the expense of compromise and risk. Airlines operate in a more-or-less organized approach. They have a schedule. They have set routes. Employees know what they are going to be doing weeks and even months in advance. On the other hand, many air charter jet businesses operate "on demand," in such a dynamic and ever-changing environment that planning and pilot schedules can be a challenge for even the most seasoned management types.
This dynamic effect can be illustrated by the following interaction between the customer, crew and Avjet management (as reported in the NTSB accident investigation):
The business assistant of the client who chartered N303GA stated, in a post accident interview, that his employer had chartered the airplane because he was hosting a party in Aspen. The business assistant indicated that Avjet called him about 1630 and informed him that the passengers were not at the airport and that the latest time the airplane could depart was 1655. He stated that he immediately began to track down the passengers and found out that all but two (including his employer) were in the airport parking lot. The charter department scheduler who handled N303GA on the day of the accident indicated that she told the business assistant that the flight would instead have to go to the airport at Rifle if the two passengers did not arrive shortly.
According to the business assistant, the passengers that had arrived boarded the airplane. The business assistant indicated that one of the pilots had spoken to one or more passengers and stated that the airplane might not be able to land at ASE because of the nighttime landing curfew. The charter customer, upon learning about this conversation, instructed his business assistant to call Avjet and relay a message to the pilot that he should "keep his comments to himself."
The business assistant stated that, when he told his employer about the possibility that the flight might have to divert, his employer became "irate." According to the business assistant, he was told to call Avjet and tell the company that the airplane was not going to be redirected. Specifically, he was told to say that his employer had flown into ASE at night and was going to do it again. The business assistant stated that he called Avjet to express his employer's displeasure about the possibility of not landing in ASE.
The charter department scheduler who handled N303GA on the day of the accident indicated that the captain stated, during an en route conversation about 1830, that it was important to land at ASE because "the customer spent a substantial amount of money on dinner."
Charter management can sometimes be "pushed" into delivering trips for their customers because the last thing they want to do is give up a trip. Many of the clients that charter jets are well-heeled types who tend to be demanding. After all, if they spend $26,000 to charter a jet, they don't want to hear that they can't get to their destination airport! This type of interaction between management, pilots, and customers can set the stage for higher-level events later on.
CRM can be defined as the use of "all available resources for the safe and efficient completion of a flight." Resources can include peripherals, such as checklists, SOPs (Standard Operating Procedures), and operations manuals. In order to avoid procedural ambiguity, the operations manual clearly states the responsibility of crewmembers from before starting engines to after engine shutdown at the end of a flight. Therefore, if pilots who have never flown together are assigned to a flight for the first time, they will at least have documented procedures for the entire duration of the flight. They can be considered as being "on the same sheet of paper."
When documented procedures are ignored or deviated from and safety issues are compromised, then problems may arise. This was the case with the Avjet crew. According to the Avjet Operations Manual in effect at the time of the accident that was dated July 15, 2000:
Page 3-6 states that the pilot-in-command "will ensure that the flight is conducted in complete compliance with all Federal, Local, and Company regulations and policies."
Page 4-4 indicates that, during the descent, the captain is responsible for conducting an approach briefing after leaving 18,000 feet but before reaching 10,000 feet. The manual instructs the captain to emphasize the following: configuration; approach speed; final approach fix altitude; decision height/minimum descent altitude; visual descent point; circling maneuver; missed approach heading, altitude, and intentions; runway information; and abnormal conditions. The manual indicates that the first officer is responsible for calling "one thousand to go" at 1,000 feet above the assigned altitude.
Pages 4-4 and 4-5 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 at the decision height or missed approach point. The first officer is responsible for the following:
- When intercepting the final approach course: call "Needle alive."
At initial downward movement of the glideslope indicator: call "Glideslope alive."
- At FAF [final approach fix]: Call "Outer marker" or "Final fix." Start timing. Visually cross-check altimeters. Then call "Altimeters check, no flags."
- 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."
Additionally, the following Federal Aviation Regulation applies to "Operating Below DH (Decision Height) or MDA (Minimum Decent Altitude)." No pilot may operate an aircraft at any airport below the authorized MDA (or continue an approach below the DH) unless the following requirements are met:
(1) The aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuvers, and for approaches conducted under part 121 or part 135 unless that descent rate will allow touchdown to occur within the touchdown zone of the runway of intended landing;
(2) The flight visibility is not less than the visibility prescribed in the standard instrument approach being used; and
(3) Except for a Category II or Category III approach where any necessary visual reference requirements are specified by the [FAA] Administrator, at least one of the following visual references for the intended runway is distinctly visible and identifiable to the pilot:
(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.
(ii) The threshold.
(iii) The threshold markings.
(iv) The threshold lights.
(v) The runway end identifier lights.
(vi) The visual approach slope indicator.
(vii) The touchdown zone or touchdown zone markings.
(viii) The touchdown zone lights.
(ix) The runway or runway markings.
(x) The runway lights.
The botched approach was the culmination of a long chain of error links initiated long before the aircraft even departed its home base. Aspen is not the type of airport to shoot an approach into, especially in marginal weather, with a flight crew that is not on "the same sheet of paper." And this crew definitely was not.
Procedural Error and Deviation During Approach Summary
- 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.
- Contrary to the airplane manufacturer's procedures, the captain deployed the spoilers after the landing gear had been extended and the final landing flaps had been selected, and he set engine power to 55 percent N2 rather than 64 percent N2.
- 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.
- Radar data and CVR comments indicated that, until the airplane began turning to the left about 10 seconds before the accident, the flight crew probably did not have the runway or its environment in sight.
It appears that the captain had a case of "push-on-itis." This is a term for a mental commitment to land the aircraft regardless of the consequences. The first officer may have neglected the step-down fix callouts because of the "halo effect." This occurs when a first officer, who is acting in a subservient role, trusts the captain's judgment because "he knows what he's doing, he'll be fine." This "trust," or non-assertive behavior, can create big problems in the cockpit. This behavior was undoubtedly compounded by a high-workload situation and elevated stress levels.
The operations manual states that callouts need to be made at various phases during the approach. The closer the aircraft is to the ground, the more important these callouts become. The first officer had a duty of calling out "Missed approach point, runway in sight" (continue) or "Missed approach point, runway not in sight" (missed approach). Instead, the crew continued past the missed approach point in an attempt to gain visual contact with the runway, violating FAA regulations as well as company-specific operations. A more assertive first officer may have made a difference at that point.
An aircraft limitation was exceeded when the spoilers were extended with the landing gear down and the flaps set to full. Again, an assertive command by the first officer may have broken a link in the chain. Both pilots had attended formal school on the aircraft and both knew that the use of spoilers in that configuration was not approved. But yet, nobody said anything.
The captains comment, "Where's it at?" at 1.4 miles from the runway was another red flag. The captain himself should have known better not to push on a bad approach at that point. And once again, it seemed like the first officer was "along for the ride."
Poor Crew Coordination Summary
- 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.
- 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.
How can a crew possibly know what their responsibilities are and what is expected of them if there is a complete lack of communication between them? One of CRM's main goals is to increase communication between pilots. With no communication, you have no synergy (teamwork), and with no synergy you are far from using all available resources for the safe completion of a flight. Both pilots need to have good situational awareness (knowing where you have been, where you are now, and where you are going). Since the captain thought this would be a relatively easy visual approach, he effectively "closed off" the first officer in the communications loop.
Since there was a lack of an approach/missed approach briefing or any urgency in respect to the approach, the first officer's lack of callouts probably came as a relief to the captain who didn't want to be "cluttered" with "non-essential chatter" during the approach anyway. On that assumption the first officer let the captain fly the approach "single-pilot" right into the ground.
Incidentally, this type of accident is called Controlled Flight Into Terrain (CFIT). CFIT is defined as "When a perfectly airworthy aircraft, under complete control of the pilot(s), is inadvertently flown into the ground, an obstacle, or water with little or no awareness by the pilot(s) until it's too late." According to the Flight Safety Foundation, CFIT is the leading cause of aircraft accidents in all operations, not just Part 135. Disturbingly, CFIT accidents are not showing a downward trend, as opposed to aircraft accidents in general.
Flight Crew Pressure Summary
The importance of contingency planning is of utmost importance. The pressure put on this crew to get into Aspen fueled the fire for a breakdown in the communication process. If the departure from Los Angeles wasn't delayed and there was no curfew at Aspen for night operations, the pressure (both real and perceived) may have had a different effect on the crew. But those two factors certainly played into the pressure of getting in to Aspen.
- 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 jump seat, especially if it were the charter customer, most likely further heightened the pressure on the flight crew to land at ASE.
If the crew was more assertive with the passengers as to the possibility of not getting in and having to go to the alternate airport, the outcome may have been different. Pressure from passengers, no matter how rich or famous they are, cannot override the good judgment and decision behavior of an experienced flight crew. Passenger pressure must be mitigated.
Notice to Airman (NOTAM) Restriction Summary
- 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.
The dissemination of critical flight information is extremely important to safe flight operations. All available resources include NOTAMs. The ambiguity with the NOTAM above gave the first officer the impression that the approach was authorized at night but the circle-to-land procedure was not. The inference that a straight in landing for Runway 15 was still authorized was very real. Because of this, critical information was dismissed by the first officer, and not passed on to the captain as part of a pre-flight briefing. Once again, the communication process had broken down.
CRM will help offset the additional workload and stress incurred in Part 135 charter operations. The key areas of variance between airline and charter operations are as follows:
- There is a higher likelihood of putting crews together with drastically different backgrounds and levels of experience.
- Flight and duty times are typically stretched to the maximum.
- Flights are conducted to smaller, more challenging airports.
- More non-precision approaches being used to get into those challenging airports.
- More pressure from management and passengers to get to your destination.
- Most, if not all, flight planning and paperwork must be completed by the flight crew.
- The quality of aircraft-specific pilot training can vary from company to company. Many pilots are independent contractors or contract pilots.
The need for CRM training for on-demand jet charter operations should be obvious from this case study. CRM will help crews in their decision processes, communicative ability, assertiveness, workload management, situational awareness and numerous other behaviors. The NTSB has made its recommendation to the FAA. Let's see how much more blood has to be shed before the FAA accepts the recommendation.
Wiener, Earl L., and Nagel, David C. (1988) Human Factors in Aviation: Human Error in Aviation Operations pp. 263-301.
Flight Safety Foundation Digest. (August-September 2001 Issue). International Organizations Rise to Challenge to Prevent Approach and Landing Accidents.
National Business Aviation Association Web site (2003). Aviation Safety Statistics. Washington D.C.
Federal Aviation Administration Web site (2003). Various Data. Washington, DC.
National Transportation Safety Board Website (2002). Aircraft Accident Brief. File # DCA01MA034. Washington, D.C.
From Flight Safety Foundation, available in Adobe's PDF format:
Reduced Visibility, Mountainous Terrain Cited in Gulfstream III CFIT at Aspen
Sabreliner Strikes Mountain Ridge During Night Visual Approach