Close-Up: Fatal Learjet Crash During ILS to IAH

On January 13, 1998, a Learjet 25B crashed two miles short of runway 26 while attempting a second ILS approach to Houston Intercontinental Airport in dense fog with visibility reported to be less than a quarter mile. The aircraft missed its first approach after the captain's directional gyro flagged and the aircraft strayed 25 degrees left of the final approach course. In addition, the aircraft had sticky glideslope needles which had been previously squawked but not fixed. Inexplicably, the experienced flight crew decided to attempt a second approach. They didn't make it. [NTSB Identification: FTW98MA096]


History of Flight

SafetyOn January 13, 1998, about 0810 central standard time, a Gates Learjet 25B, N627WS,impacted terrain approximately 2 nautical miles (nm) east of the runway 26 threshold atGeorge Bush Intercontinental Airport (IAH), Houston, Texas, during an instrument landingsystem (ILS) approach. (All times in this report are central standard time, based on a24-hour clock.) The airplane was operated by American Corporate Aviation, Inc., of Houstonand was registered to First Star, Inc., of Wilmington, Delaware. The positioning flight,which was operating under 14 Code of Federal Regulations (CFR) Part 91, had departed fromHouston’s Hobby Airport (HOU) about 0745 with a destination of IAH. The captain and firstofficer were the sole occupants aboard the flight. Instrument meteorological conditionsprevailed for the flight, and an instrument flight rules (IFR) flight plan had been filed.Both flight crewmembers were killed, and the airplane was destroyed by impact forces andfire. Five people were waiting at IAH to board the airplane for a 14 CFR Part 135 charterflight to Fargo (FAR), North Dakota.

The airplane had been operated from Raytheon Aircraft Services, a fixed-base operator(FBO) at HOU, for about 1 month before the accident flight. Raytheon’s records indicatedthat, on January 12, 1998, the Director of Operations for American Corporate Aviationverbally requested fuel for the airplane and that the wing and tip tanks were “toppedoff” with 372 gallons of jet fuel. During the afternoon of January 12, the captain ofthe accident flight taxied the airplane from Raytheon Aircraft Services to FletcherAviation, another FBO at HOU, and the airplane was placed in a hangar. About 1700, thedirector of operations and the captain removed a stretcher from the airplane and installedtwo passenger seats in its place. According to the director of operations, he discussedthe next day’s trip to Fargo with the captain and informed him who the first officer forthe flight would be. The director of operations stated that he later observed the captaingiving the first officer a preflight briefing.

The proposed round trip consisted of four flight segments: HOU to IAH, IAH to FAR, FARto IAH, and IAH to HOU. According to the transcript of the telephone call, about 0528 onJanuary 13, 1998, the captain called Montgomery County Automated Flight Service Station(CXO AFSS) and filed an instrument flight plan for a flight in N627WS from HOU to IAH andthen from IAH to FAR. The proposed departure times from HOU and IAH were 0645 and 0800,respectively. When the briefer at CXO AFSS asked the captain if he could do anything else,the captain said, “yeah tell me how bad the weather is I know it is foggy as ason-of-a-gun.” The captain was then given a weather briefing for the Houston andFargo areas. The weather at IAH was reported as 1/4-mile visibility restricted by fog,vertical visibility of 100 feet, and temperature and dew point within 1 degree of eachother. The forecast weather for FAR after 0900 called for unrestricted visibility andscattered clouds at 12,000 feet, becoming overcast at 10,000 feet between 1200 and 1400.The captain concluded the conversation about 0534 after saying, “well ok I’m justgoing to take my time and mosey on out to the airport after it gets a little better I’llget an update with you then we’ll go.”

While this briefing was being conducted, CXO AFSS received another telephone call about0532 requesting a weather briefing for N627WS departing HOU at 0800 for a flight to IAHand then FAR. In an interview conducted during the accident investigation, the ChiefExecutive Officer (CEO) of American Corporate Aviation indicated that he placed this callto CXO AFSS. The CEO was told that the weather at HOU was calm winds, 1/8-mile visibilityrestricted by fog, an indefinite ceiling at zero feet, and both the temperature and dewpoint at 19 degrees Celsius (C). The weather at IAH was reported as calm winds, 1/4-milevisibility restricted by fog, an indefinite ceiling at 100 feet, and both the temperatureand dew point at 17 degrees C. The call was concluded about 0540.

A line service technician employed by Fletcher Aviation stated that, when he arrivedfor work about 0605, the captain was already at the FBO. About 0612, the captain calledCXO AFSS again, asking if the weather at IAH had gotten any better. He was told that theweather was reported as 3/4-mile visibility restricted by fog with an indefinite ceilingat 100 feet. CXO AFSS received a third call from the captain about 0646 requesting IAHweather. The captain was given a special weather report issued about 0606; the reportedconditions included 1/4-mile visibility restricted by fog, light rain, indefinite ceilingat 100 feet, temperature and dew point within 1 degree, and occasional lightning in cloudsfrom a thunderstorm to the south moving northeast. About 0706, CXO AFSS received a fourthcall from the captain, asking if IAH weather had improved. The captain was told that theweather was reported as 1/4-mile visibility restricted by mist, an overcast ceiling at 100feet, surface visibility of 4 miles, and a thunderstorm in the vicinity.

According to the Fletcher Aviation line service technician, the first officer arrivedat the airport between 0645 and 0700. The airplane was then moved from inside the hangarto the ramp, and the technician connected a power cart to the airplane. At that time, thetechnician heard fuel being transferred to the fuselage fuel tank. The technician observedthe first officer fill out a “trip log” form, which the technician faxed toAmerican Corporate Aviation’s “dispatch” office after the airplane taxied out.Safety Board investigators obtained a copy of this document from the CEO of AmericanCorporate Aviation. The form was a copy of page 9.28 of American Corporate Aviation’sOperations Manual, entitled “Dispatch Record.” The form indicated that the routeof flight would be HOU-IAH-FAR-IAH-HOU and that the IAH-FAR-IAH portion of theflight would be operated under 14 CFR Part 135.

According to cockpit voice recorder (CVR) data, the captain was the flying pilot on theflight from HOU to IAH, and the first officer was the nonflying pilot. After an uneventfultakeoff from HOU, the first officer made initial contact with the IAH Terminal RadarApproach Control (TRACON) Departure North controller about 0746:21. The controller beganvectoring the flight for an ILS approach to runway 26 at IAH and transmitted the followingIAH automatic terminal information service (ATIS) weather conditions:

[information] Echo is current. wind is three four zero at seven. visibility’s one half, mist. ceiling is two hundred broken, six hundred broken, nine hundred overcast. temperature one eight. Humble altimeter three zero, zero one. Remarks, surface visibility is five. Runway two six RVR [runway visual range] is more than six thousand.

The Departure North controller then handed off the flight to the Arrival Eastcontroller. After a series of turns, the flight was cleared about 0751:43 for the approachto IAH and instructed to contact the IAH tower. The CVR recording does not indicate thatthe flight crew conducted a verbal approach briefing.

About 0752:51, the IAH Air Traffic Control Tower (ATCT) Local West controller clearedthe flight to land on runway 26. Radar data indicated that the airplane began a descentfrom 2,000 feet mean sea level (msl) about 0753:17 from about 0.5 nm inside NIXIN (thefinal approach fix) on the left edge of the localizer course. The airplane descended to1,600 feet msl, where it intercepted the center of the localizer course approximately 1.5nm inside NIXIN. About 0753:47, the CVR recorded the captain stating, “I got acompass flag.” Immediately after the captain’s comment, the airplane departed thelocalizer centerline to the left, establishing a course about 25 degrees left of the finalapproach course. The airplane continued on this course for approximately 50 seconds anddescended to about 700 feet msl.

According to CVR data, about 0754:36 the first officer said, “you wanna go missedand go back? it shows you right of course.” The captain responded, “yeah yeahtell him we go missed.” About 0754:41, the local controller said, “Lear uh,seven Whiskey Sierra uh, say heading.” The first officer responded, “uh, we needto go missed…. we’re going missed approach.” A missed approach was then initiatedfrom about 0.8 nm from the threshold of runway 27 on its extended centerline. (Runway 27is south of and parallel to runway 26.) The flight was assigned an altitude and heading tofly and switched from local control back to approach control.

About 0756:05, the first officer told the controller, “we need to go back toIntercontinental or uh back to uh, Houston Hobby.” The captain said to the firstofficer, “no, we just need to fly around a bit.” The first officer then told thecontroller, “captain says, uh, we’re gonna fly around if you can put us out uh, we’regonna try to straighten something out.” The controller asked, “do you have aproblem with the aircraft?” The first officer replied, “just the compass. we’reworking on it.” According to CVR data, the captain and first officer spent the nextfew minutes attempting to clear the compass flag by resetting circuit breakers. The CVRrecording provides no indication that the problem was resolved.

About 0759:10, the captain said, “well let’s go back to Hobby, we can’t, we can’tdo a trip like this,” but then said, “well now let’s think about this asecond.” The first officer asked the captain about the weather conditions in NorthDakota. The captain replied that it was “severe clear” and then said, “uh,let’s go on and try Intercontinental again.” About 0759:42, the first officerrequested another approach to IAH.

The controller began vectoring the flight for a second ILS approach to runway 26,instructing the flight crew to “fly heading three five zero.” About 0759:58, thecaptain said, “right turn to three five zero?” and the first officer replied”yeah.” Radar data indicated the airplane began to turn right from an eastboundheading toward the south. The controller noticed that the airplane was turning southboundand instructed the flight crew to “turn northbound heading three, six, zero.”The first officer acknowledged the controller’s correction, and the airplane began to turnleft. Afterward, the first officer made three statements to the captain about his radiomagnetic indicator (RMI). The first officer said, “threeee six zero. watch yourRMI” (about 0801:32); “RMI three six zero going….” (about 0801:44); and”watch the RMI” (about 0802:12).

About 0801:55, the controller transmitted the following IAH ATIS weather conditions:

information Foxtrot is current…. the wind three five zero at six. the uh, weather is less than a quarter mile visibility light rain and uh, mist. two hundred broken uh, measured ceiling two hundred broken, six hundred overcast. altimeter three zero zero one the runway two six RVR’s more than six thousand.

After a series of turns, the flight was cleared about 0806:22 for the approach andinstructed to contact the IAH tower. The CVR recorded no discussion or briefing on how theapproach would be flown. About 0807:53, the Local North controller cleared the flight toland on runway 26. About 0808:03, the first officer said, “OK, you are cleared toland. apparently, it the glideslope (isn’t) working. I can’t watch it….” At thispoint, radar data indicated that the airplane was about 1.1 nm outside NIXIN on theglideslope and inside the left half of the localizer course.

The airplane remained within the left half of the localizer course and on or slightlyabove the glideslope until it reached a point approximately 0.6 nm inside NIXIN. Theairplane then traveled momentarily outside the left edge of the localizer course. About0808:34, the first officer said, “…quit turning, quit turning. we’re gonna gothrough it. follow mine right here.” After the first officer’s comment, theairplane’s course varied slightly to the right and began to converge with the localizercourse. As the airplane neared the localizer centerline (about 0808:52), the first officersaid, “OK, ease your wings back. to the right, to the right, to the right….”The captain then stated, “all right. Can you fly it?” The first officer replied,”yeah, I think so.”

When the transfer of control from the captain to the first officer took place, theairplane was approximately 1.9 nm inside NIXIN (3.8 nm from the runway threshold),slightly below the glideslope and on the localizer centerline. About 0809:08, the captainasked, “where’s your glideslope?” The first officer replied “righthere,” and the captain said, “look at it.” About 0809:21, the first officerstated, “…we are way above glideslope.” The captain responded, “right.ease it on down.” At this point, the airplane was between 200 and 300 feet below theglideslope. About 0809:30, the first officer said, “all right, where’s the missedapproach point…?” The captain replied, “two hundred feet.” (The publisheddecision height for the approach was 296 feet msl, or 200 feet above ground level (agl).)About 0809:45, the first officer said, “OK. three hundred feet to missed. OK, I’mbreaking out.” The captain responded, “don’t don’t you look up.”

The last radar position for the airplane, recorded about 0809:48, was approximately 2.2nm from the runway threshold, about 400 feet below the glideslope, at an altitude ofapproximately 400 feet msl. About 0809:54, the CVR recorded a slapping sound that wasfollowed by the sound of impact. The CVR stopped recording about 0809:56.

The accident occurred during daylight approximately 2 nm from the threshold of runway26 and along the extended runway centerline. The elevation of the accident site wasapproximately 100 feet msl. The airplane initially struck trees about 80 feet tall. Thecockpit/cabin area was found approximately 860 feet west of the initial tree strike at 29degrees 59.563 minutes north latitude and 095 degrees 17.26 minutes west longitude. Therewere no witnesses to the accident.

Personnel Information

Neither the captain nor the first officer had any Federal Aviation Administration (FAA)record of airplane accidents, incidents, or enforcement actions. Interviews with immediatefamily members and acquaintances disclosed no evidence of any activities that would haveprevented either flight crewmember from obtaining sufficient rest in the 72 hours beforethe accident.

The Captain

The captain, age 52, held an airline transport pilot certificate with the ratings andlimitations of airplane multiengine land; commercial privileges for airplane single-engineland; and type ratings for the Learjet, IA-JET, and HS-125. The captain obtained hisLearjet type rating on February 6, 1987. His most recent FAA first-class medicalcertificate was issued on October 7, 1997, with the limitation that he wear correctivelenses for distant vision and possess corrective lenses for near vision while acting as apilot.

According to the captain’s flight logbook, he had accumulated 8,777 total flying hours,of which 2,512 were in the Learjet. He had flown 19, 100, and 610 hours in the past 30days, 90 days, and 1 year, respectively. The logbook indicated that the captain had flownone previous trip in N627WS; that trip occurred on December 23, 1997, and included about6.9 hours of flying time. The captain’s most recent Learjet recurrent simulator trainingwas accomplished in October 1997 at the facilities of SimuFlite Training International.This training consisted of 12 hours of ground school and 9 hours of flight simulator time.

Pilot training records reviewed during the accident investigation indicated that thecaptain had satisfactorily completed the training and testing requirements to act aspilot-in-command (PIC) of a Learjet 24 or 25 for three Houston-area 14 CFR Part 135operators. These operators were Aviex Jet, American Corporate Aviation, and Executive AirCharter, and the required training and testing for each were completed on January 22,August 15, and December 9, 1997, respectively. The captain was qualified to act as PIC ofa Learjet 25 for Aviex Jet and American Corporate Aviation and of a Learjet 24 forExecutive Air Charter.

At the time of the accident, the captain was working as a contract pilot and had nofull-time employment. From July to December 1997, Linrose Aviation, Inc., of Longview,Texas, employed the captain as PIC of a Learjet 25D. According to the vice president ofLinrose Aviation, the captain’s employment was terminated because of his failure to followcompany rules and not because of unsatisfactory flying skills.

Interviews were conducted with pilots and check airmen who had flown with the captainin the Learjet. These personnel described the captain as an experienced pilot with anoutgoing, friendly personality. Comments concerning the captain’s flying skills weregenerally favorable. However, the check airman for Aviex Jet stated that the captain was”well above average, but not the best in pilot skills.”

The First Officer

The first officer, age 39, held a commercial pilot certificate with the ratings andlimitations of airplane single- and multiengine land, instrument airplane, and a visualflight rules (VFR)-only DC-3 type rating. Additionally, she held a flight instructorcertificate with airplane single- and multiengine land and instrument airplane ratings.Her most recent FAA first-class medical certificate was issued on November 6, 1997, withno limitations or restrictions.

According to the first officer’s flight logbook, she had accumulated 2,237 total flyinghours, of which 350 hours were in the Learjet. She had flown 38, 143, and 597 hours in thepast 30 days, 90 days, and 1 year, respectively. The logbook indicated the first officerhad flown six previous trips in N627WS for a total of 21.4 flight hours; the most recenttrip occurred on December 24, 1997. Her initial Learjet simulator training wasaccomplished in April 1997 at the facilities of Flight Safety International. This trainingconsisted of 14 hours of ground school and 18 hours of flight simulator time.

Pilot training records reviewed during the accident investigation indicated that thefirst officer had satisfactorily completed the training and testing requirements to act assecond in command of a Learjet 25 or 35 for three Houston-area 14 CFR Part 135 operators.The operators were Aviex Jet, Air America Jet Charter, and American Corporate Aviation,and the required training and testing for each was completed on June 30, July 31, andAugust 6, 1997, respectively. The first officer was qualified to act as second in commandof a Learjet 25 for all three operators and of a Learjet 35 for Air America Jet Charter.At the time of the accident, the first officer was working as a contract pilot andpart-time flight instructor. She had no full-time employment.

Interviews were conducted with captains and check airmen who had flown with the firstofficer in the Learjet. These personnel described the first officer as a hard worker witha strong desire to improve her knowledge of the airplane and obtain a type rating.Regarding the first officer’s piloting skills, comments by captains included “for alow-time pilot [she] did a pretty good job” and “[she] flew like she was readyto get her Learjet type rating.” However, the check airman for Aviex Jet stated thatthe first officer “was at minimum proficiency and capability.” The check airmanbelieved that the first officer was not “cut out to be a charter pilot,” statingthat “her biggest problem was basic hand-eye coordination. She was easily overloaded.She would be fine if she were paired with a strong pilot in command.”

Airplane Information

N627WS, a Gates Learjet 25B, serial number (S/N) 170, was issued an airworthinesscertificate on June 5, 1974. The airplane was configured to carry eight passengers and twopilots and was equipped with two General Electric model CJ610-6 turbojet engines rated at2,950 pounds of thrust. The last major inspection of N627WS, which had been operated byAmerican Corporate Aviation since July 1997, was a 600-hour inspection accomplished onAugust 31, 1997. At that time, the airplane had accumulated 8,913 flight hours. The CEO ofAmerican Corporate Aviation estimated that the airplane had flown approximately 30 hourssince the time of the last inspection.

Weight and Balance

The airplane’s weight and balance were calculated for both takeoff at HOU and landingat IAH. The calculated takeoff gross weight of 13,283 pounds and center of gravity (CG) of28.85 percent mean aerodynamic chord (MAC) were within the takeoff limits (15,000 poundsand 13.9 to 30 percent MAC, respectively). The calculations for landing at IAH, predicatedon a fuel burn of 1,042 pounds, indicated that the landing weight would have been 12,241pounds and that the CG would have been 29.05 percent MAC. These values were within thelanding limits of 13,300 pounds and 12.5 to 30 percent MAC, respectively. According to theGates Learjet 25B/25C Flight Manual, the landing approach speed (VREF) for the calculatedlanding weight was 121 knots.

Flight Director System

The airplane was equipped with two Bendix FD-60 Flight Director Systems, one each forthe captain and first officer positions. An FD-60 system consists of a course deviationindicator (CDI), horizon and director indicator (HDI), control panel, flight steeringcomputer, and flight instrument amplifier. Each system also receives input from a remotedirectional gyro for heading information. The system consolidates navigational andattitude information, computes combined roll and pitch steering commands, and displays allinformation on the CDI and HDI. The FD-60 functions independently of the airplane’sautopilot.

The CDI is a primary cockpit instrument that displays magnetic (or compass) heading andprovides a pictorial presentation of aircraft displacement relative to VOR radials,localizers, and glideslope beams. It is also referred to as a horizontal situationindicator (HSI). According to the Pilot’s Familiarization Handbook for the FD-60 system,the CDI has an emergency mode that allows continued use of data from radio aids whenheading information is unreliable. The pilot selects this mode by pulling out the coursecrank (or knob). Once in the pulled-out position, the knob can be turned to manuallyrotate the compass card and associated displays in relative positions to orient the coursedeviation needle parallel to the instrument’s vertical axis. The HDI is a primary cockpitinstrument that displays aircraft attitude, localizer, and glideslope beam information;speed command deviation; and computed pitch and roll steering commands. It is alsoreferred to as an attitude director indicator (ADI).

The appearance of a compass warning flag on the CDI indicates that the heading displayis unreliable. According to technical specifications published by the manufacturer, acompass warning flag would come into view on the CDI if one of the following eventsoccurred: (1) a loss of electrical power to system components, (2) a failure of the remotedirectional gyro, or (3) the function of the compass display servomechanisms becomesunreliable. The compass display servomechanisms are controlled by the flight instrumentamplifier with input from the remote directional gyro.

Maintenance Records Review

The aircraft maintenance logbook for recording mechanical irregularities, which wasrequired by 14 CFR Section 135.65 to be on board the airplane, could not be identifiedduring examination of the airplane wreckage. On January 16, 1998, 3 days after theaccident, the CEO of American Corporate Aviation sent a facsimile to the Safety Board,stating the following:

I have found notes from a flight 11-12-97 of avionics problems that were entered on the aircraft Discrepancy Maintenance Log.

  • #1 VOR will not channel 117.6 & 101.9

  • GPS [global positioning system] falls off the keeps re-cap and holding sig 5 to 10 min.

Copies of work order authorizations that described the avionics problems were obtainedfrom Raytheon Aircraft Services. The records indicate that three discrepancies, or”squawks,” were reported to Raytheon on November 13, 1997, for repair.

The first squawk read, “#1 NAV OUT ON 117.6.” The associated inspection cardstated that the following corrective actions were taken:

Removed nav RX [receiver] bench checked good hot & cold, removed Gables control cleaned & lubricated ops check good in a/c. NOTE: NOT VERIFIED.

The second squawk read, “#2 GLIDESLOPE OUT ON 109.9.” The associatedinspection card stated that the following corrective actions were taken:

Ground checked operation confirmed both ADI & HSI G.S. [glideslope] pointerssticks. Note: advised customer, repairs deferred until such time available to send unitsout to mfr.

The third squawk read, “GPS LOSES POSITION.” The associated inspection cardstated that the following corrective actions were taken:

Ground checked operation system does not receive satellites suspect ANT [antenna] problem. Connected another GPS ANT for test system worked OK. Note: original antenna no longer available. Consulted with Northstar. They provided an acceptable substitute. This unit required rework of the mounting area on the aircraft. Customer contracted with local facility (Flight Vehicles) for mounting of replacement antenna. Still have problem. M6 GPS sensor S/N 688, CDU [control display unit] S/N R00142 sent to mfr for repair 12-11-97.

Examination of the airplane’s maintenance records revealed an entry on November 13,1997, that corresponded to the three squawks. This entry, which was the last one in themaintenance records, stated the following:

Removed #1 VIR-30A VOR/ILS rcvr. s/n 1672, and Gables control for the Nav, s/n 001, VIR-30A checked to specs, no trouble found. Cleaned and lubricated control unit. Checked #2 Glideslope in the aircraft, found Glideslope pointer in both ADI and HSI to be sticking, co-pilots position. No action taken at this time. Removed Northstar M6 GPS sensor s/n 688 and CDU s/n R00142 for evaluation by the manufacturer.

In an interview conducted during the accident investigation, the Director of Operationsfor American Corporate Aviation was asked if he was aware of any problems with theairplane before the accident. The official replied that he was aware of only a problemwith the GPS, which had been removed and sent to the manufacturer for repair. The directorof operations further stated that he did not think there were any other problems with theairplane and that his company was “good” about fixing maintenance discrepancies.According to the official, N627WS did not fly very much, so taking it out of service formaintenance for a short time did not greatly affect the company’s operations.

Minimum Equipment List

Title 14 CFR Section 135.179 provides for the operation of an aircraft under 14 CFRPart 135 with inoperable instruments or equipment installed. The rule requires that thecertificate holder (operator) have an approved minimum equipment list (MEL) for thespecific make and model of aircraft and that the use of the approved MEL be authorized inthe certificate holder’s operations specifications. Additionally, the rule states that theaircraft must be “operated under all applicable conditions and limitations containedin the Minimum Equipment List and the operations specifications authorizing use of theMinimum Equipment List.”

Review of the operations specifications for American Corporate Aviation indicated thatthe company was authorized to use an FAA-approved MEL. A copy of the approved MELapplicable to N627WS was obtained from the CEO of American Corporate Aviation. Accordingto page 34-2 of the MEL, dated April 15, 1997, the airplane was equipped with two”VHF Navigation Systems (VOR/ILS).” The MEL stated that “both may beinoperative provided flight is made VFR outside TCA [terminal control area]. COMPLY WITHPM 2,3.” (The Procedures Manual section of the MEL identified PM 2 and PM 3 asPlacarding Procedures and Crew Operating Procedures, respectively.) The MEL indicated thenavigation systems were Category C repair interval items. According to the Definitionssection of the MEL, Category C items “shall be repaired within ten (10) consecutivecalendar days (240 hours), excluding the day the malfunction was recorded in the aircraftmaintenance record/logbook.”

Title 14 CFR Section 91.213 provides for the operation of an aircraft under 14 CFR Part91 with inoperative instruments or equipment installed. The rule states that “aperson authorized to use an approved Minimum Equipment List issued for a specific aircraftunder part 121, 125, or 135 of this chapter shall use that Minimum Equipment List inconnection with operations conducted with that aircraft under this part without additionalapproval requirements.”

Meteorological Information

The 0600 and 0900 surface analysis charts of the National Weather Service (NWS)depicted a cold front approaching the accident area, stretching from southern Texas tocentral Louisiana. The Houston area remained south of the front. In this warm air sector,an extensive area of fog and mist was reported along the Texas and Louisiana coastlinealong with scattered rain showers and thunderstorms.

The NWS-reported weather conditions at IAH surrounding the time of the accident were asfollows:

At 0753, winds 350 degrees at 6 knots, tower visibility less than 1/4 mile in light rain and mist, ceiling broken at 200 feet and overcast at 600 feet, temperature 18 degrees C, dew point 17 degrees C, altimeter setting 30.01 inches of mercury [Hg]. Remarks: ASOS [automated surface observation system], surface visibility 6 miles, ceiling 100 variable 500 feet, sea level pressure 1016.1 millibars, precipitation within the last hour 00.00 inches.

At 0804, winds 360 degrees at 8 knots, tower visibility less than 1/4 mile in light rain and mist, scattered clouds at 200 feet, ceiling broken at 800 feet, temperature 18 degrees C, dew point 17 degrees C, altimeter 30.02 inches of Hg. Remarks: ASOS, surface visibility 6 miles, ceiling 600 feet variable 900 feet, precipitation 00.01 inches.

At 0820, winds 340 degrees at 4 knots, tower visibility less than 1/4 mile in light rain and mist, scattered clouds at 600 feet, ceiling overcast at 1,000 feet, temperature 18 degrees C, dew point 17 degrees C, altimeter setting 30.02 inches of Hg. Remarks: ASOS, surface visibility 5 miles, precipitation 00.01 inches.

The NWS terminal forecast for IAH, issued at 0540 and pertinent for the indicatedtimes, called for the following:

Beginning at 0600, winds calm, visibility 1/4 mile in fog, vertical visibility 100 feet into the obscuration, temporarily between 0600 and 0800, light rain showers. From 0800, winds 350 degrees at 9 knots, visibility 3 miles in mist, clouds scattered at 100 feet, ceiling overcast at 1,200 feet, temporarily between 0800 and 1000, visibility 1 mile in light showers of rain and mist, ceiling broken at 100 feet. Amendment at 0609, temporarily between 0600 to 0800, thunderstorms and light rain, ceiling broken at 100 feet with cumulonimbus clouds.

IAH Terminal Doppler Weather Radar (TDWR) archive data from 0745 to 0815 showed nomicroburst, wind shift, gust front, or other wind-shear features. The TDWR systemidentified a few level 1 radar echoes within the 5-mile range of IAH; however, no radarechoes were noted over runway 26 or eastward along the 4-mile approach area. At the15-mile range, the system identified a small area of level 1 radar echoes beyond 5 mileson the extended centerline of runway 26.

Aids To Navigation

Runway 26 is served by an ILS with distance measuring equipment. An outer compasslocator, identified as NIXIN, is co-located with the outer marker, 5.7 nm from the runwaythreshold. After the accident, the ILS was flight checked by the FAA. All components,except for the inner marker, were found to be operating within prescribed tolerances. (Theinner marker is used only for Category II and III approaches, which are ILS approaches toreduced weather minimums under special rules of certification for the crews, runways, andequipment.)

Airport Information

IAH is owned and operated by the City of Houston, Texas. The airport is locatedapproximately 15 miles north of Houston and has an elevation of 98 feet msl. IAH has fourrunways: 08/26, 09/27, 14L/32R, and 14R/32L. Runway 08/26 is 9,401 feet long and 150 feetwide with a grooved asphalt/concrete surface. It is equipped with a high-intensityapproach lighting system with centerline sequenced flashers; high-intensity runway edgelights; and a touchdown, midpoint, and rollout RVR system. The runway’s touchdown zoneelevation is 96 feet msl.

Flight Recorders

A flight data recorder (FDR) was not installed in N627WS, and 14 CFR Part 91 and 135did not require the airplane to be so equipped. The CVR installed on the airplane was aFairchild model GA100. The voice recording consisted of three channels of good-qualityaudio information. One channel contained the cockpit area microphone audio information,and the two other channels contained the captain’s and first officer’s audio panelinformation. A transcript was prepared of the entire 30-minute 56-second recording.

Wreckage And Impact Information

Accident Site Details

The terrain at the accident site was level and consisted of soft, wet dirt withnumerous trees measuring about 80 feet in height. Evidence of a freshly severed treetopmarked the beginning of the wreckage distribution path. The cockpit/cabin area was foundabout 860 feet on a magnetic bearing of 263 degrees from this tree.

The initial piece of wreckage, found about 155 feet beyond the initial severed treetop,was a piece of wing skin. More pieces of wing skin were found along the wreckage path,including the cover-plate of the left wing flap push-pull tube, which was found about 300feet beyond the initial severed treetop. This piece of wreckage was followed, in order, bythe left and right main landing gear (MLG) doors, right flap, right horizontal stabilizertip, left horizontal stabilizer skin pieces, and stinger cap. Evidence of scorched treelimbs was found beginning about 470 feet beyond the initial severed treetop. This evidencewas followed, in order, by the airplane’s radome, left elevator, left wing spoiler, leftwing flap, tail surfaces, wing structure, MLG struts, and right engine. The final piecesof wreckage found included portions of the fuselage structure, the cockpit/cabin area, andthe left engine.

Most of the wreckage that was found along the final one-third of the distribution pathsustained extensive thermal damage. However, the avionics equipment that was installed inthe nose of the airplane, which was found downrange of the burnt cockpit/cabin area, didnot receive any thermal damage. No evidence of an in-flight structural failure orin-flight fire was found at the accident site.


The left engine, a General Electric model CJ610-6, S/N 240088, had separated from theairframe and was found about 870 feet from the initial severed treetop along the wreckagepath. This engine was resting about 5 feet beyond the cockpit/cabin area and 90 feetbeyond the right engine. A gross external examination of the engine did not reveal anyevidence of an uncontained engine failure or preimpact mechanical malfunction. The thrustreverser was found in the stowed position. The stage 1 compressor rotor blades exhibitedchordwise leading edge tip curling and tearing. Obstructed views of stage 1 stator vanesand stage 2 rotor blades revealed additional leading edge and trailing edge distortion andtearing. All stator airfoil damage was in the direction of rotation, and all rotor airfoildamage was opposite the direction of rotation. To allow a visual examination of thecombustor section, Safety Board investigators removed both combustor borescope covers. Theexamination revealed significant volumes of burnt compressed wood particles adhering tothe forward facing step along the aft edge of each of the two borescope ports.

The right engine, a General Electric model CJ610-6, S/N 249105, had separated from theairframe and was found about 780 feet along the wreckage path from the initial severedtreetop. This engine was resting about 80 feet up-range of the cockpit/cabin area and 90feet up-range of the left engine. Examination of the engine did not reveal any evidence ofan uncontained engine failure or preimpact mechanical malfunction. The thrust reverser wasfound in the stowed position. All stage 1 and stage 2 rotor blades were severely bentopposite the direction of rotation. The outboard two-thirds of each stage 1 rotor bladewas bent about 45 to 60 degrees opposite the direction of rotation. To allow a visualexamination of the combustor section, Safety Board investigators removed the leftcombustor borescope cover. The examination revealed a small amount of compressed woodparticles adhering to the forward facing step along the aft edge of the borescope port andthe mating location of the port cover. The wood particles were partially burnt, oilsoaked, and black in color.


Most of the fuselage structure was found near the end of the wreckage distributionpath. Fire and impact forces destroyed about 90 percent of the structure. The cabin doorwas found in its correct, stowed position and was intact on its frame. The forward portionof the fuselage structure was found lying upright, and the rearward portion of thefuselage was found twisted around a tree and lying upside down. The horizontal stabilizer,both elevators, and the rudder had separated from the fuselage. The vertical stabilizerremained attached to the fuselage.

The entire cockpit area was completely consumed by the fire. No readings or positionsof instruments, switches, circuit breakers, and/or controls could be obtained. Both of theCDIs were identified and extracted from the wreckage, but only their chassis had survivedthe fire. The CDI compass cards and associated servomechanisms were destroyed. Anexamination of the course cranks, spline shafts, and gear teeth revealed that both crankswere found in the “normal” operational mode position.

Both wings had separated from the fuselage and broken into numerous sections. Anexamination of the separated pieces revealed evidence of tearing and tensile overload.

The largest section of the right wing was found about 690 feet from the initial severedtreetop. This section had the right spoiler attached to it and was about 3 feet in lengthand width. The right spoiler and its actuator were found retracted. The right wing fueltip tank, aileron, and flap were found separated and scattered along the wreckage path.The right wing flap, which had lodged in a tree, exhibited evidence of impact damage onits lower surface and leading edge. The flap actuator was found extended beyond itsmaximum travel limit of 45 degrees.

The largest section of the left wing was found about 730 feet from the initial severedtreetop. This section was the outboard portion of the wing, including its attached fueltip tank and aileron. The left flap and spoiler were found separated from the left wingand scattered along the wreckage path. The left spoiler actuator was not recovered. Theleft wing flap was recovered in two pieces and exhibited evidence of impact damage. Theflap actuator was found extended beyond its maximum travel limit of 45 degrees.

All flight controls were found along the wreckage path. No evidence of a preimpactflight control malfunction was found. However, flight control cable continuity could notbe established because of extensive impact and fire damage. The aileron and rudder trimtabs were found in their neutral positions. The horizontal stabilizer was trimmed toapproximately 4.3 degrees leading edge down.

The left MLG assembly, including its actuating rod, had been torn away from the wingand was found lying in the cockpit/cabin area. The assembly incurred substantial firedamage. An examination of the left MLG actuator revealed that it was in the extendedposition. The right MLG assembly had also separated from the wing and was broken apartinto several sections. These sections were found between 730 and 780 feet from the initialsevered treetop. Impact damage to the right MLG actuator precluded a determination of itsposition. The nose wheel tire assembly and lower strut were found about 650 feet from theinitial severed treetop and about 60 feet to the south of the wreckage path.

Medical And Pathological Information

Autopsies conducted by the Harris County, Texas, Medical Examiner determined that thecause of death for both pilots was blunt force injuries and extensive thermal body burns.The medical examiner took specimens from both pilots, including liver, lung, kidney,spleen, and muscle tissues. Blood, urine, and vitreous humor samples were not availablebecause of the effects of the fire.

The FAA Civil Aeromedical Institute’s (CAMI) Forensic Toxicology and Accident ResearchCenter examined the specimens taken by the medical examiner. According to CAMI, thespecimens showed no indication of drugs of abuse. For both pilots, values of ethanol,acetone, and acetaldehyde exceeded concentration levels normally reported. Because of thelack of blood, urine, and vitreous humor samples, CAMI was unable to determine whetherthese concentrations were derived from post-mortem microbial action or pre-mortem alcoholingestion. The medical examiner’s toxicological analysis, performed closer to the time ofdeath, indicated that no alcohol or performance-impairing drugs were present at the timeof death.


Fire damage to the airplane wreckage was consistent with a fuel-fed fire erupting onimpact.

Survival Aspects/Emergency Response

The accident was not survivable.

The initial notification of a missing airplane was made about 0817. The IAH ATCTcontacted the Houston Fire Department stations on the airport, via the crash phonenetwork. About 0855, after searches of the IAH aircraft operating area failed to locatethe airplane, a search began beyond the operating area in the woods east of Lee Road(approximately a 3/4 by 2-mile area east of runway 26). Personnel from the Houston Fireand Police Departments, Harris County Sheriff’s Department, and IAH Aviation Departmentparticipated in the search. Limited visibility, thick woods, swampy grounds, and the lackof roads or paths in the area hampered the ground search.

About 0906, the IAH Aviation Department requested assistance from the Houston PoliceDepartment helicopter unit, but it was unable to respond because of the IFR weatherconditions. About 0910, the aviation department requested the assistance of a U.S. CoastGuard helicopter. IAH Aviation Department personnel located the airplane about 1012. Otheremergency response personnel began to arrive at the accident scene about 1017, and theyreported that the two occupants had not survived the accident.

Tests And Research

Flight Instrument Amplifiers

Both flight instrument amplifiers were mounted in the nose compartment of the airplane.They exhibited external impact damage but were not burned. An examination of themaintenance records did not reveal which amplifier S/N was part of the captain’s flightdirector. Therefore, both amplifiers were tested for any anomalies that could haveresulted in the extension of a compass flag in the captain’s CDI.

The flight instrument amplifier marked as S/N 7404101 was examined first. Its case wasdented and had one entire side missing. Dirt was found imbedded in the cannon plugconnector. All three fuses were intact and not blown. The case was pried away from thecircuit boards, and all four cards were removed. An examination of the boards did notreveal any evidence of thermal damage, crushing, or loose debris. A capacitor lead on the412-A1 command circuit card was separated from the board, and a corroded lead from anothercapacitor was found on the same board; however, this board is not used to excite thecompass flag.

The power supply circuit card was extracted from the unit and tested according to themanufacturer’s overhaul instructions. The results of the testing were all within publishedspecifications, and no anomalies were found.

The 412-A3 heading circuit card was also tested. However, test equipment for theamplifier, because of its age, was no longer provided by the manufacturer and could not befound at numerous avionics shops contacted by the Safety Board. With the use of schematicsprovided by the manufacturer, circuitry that simulated the manufacturer’s test equipmentwas fabricated and used to test the heading circuit card according to the manufacturer’soverhaul instructions. The results of the testing were all within publishedspecifications, and no anomalies were found.

The flight instrument amplifier marked as S/N 7504102 was examined second. Its case wasdented and had one entire side missing. All three fuses were intact and not blown. Thecase was pried away from the circuit cards, and all four cards were removed. Anexamination of the cards did not reveal any evidence of thermal damage, crushing, or loosedebris. A small amount of dried dirt adhered to sections of all of the cards.

The power supply circuit card and heading circuit card were extracted from the unit andtested according to the manufacturer’s overhaul instructions. The results of the testingwere all within published specifications, and no anomalies were found.

Directional Gyros (Directisyns)

The airplane was equipped with two remote directional gyros, known as directisyns. Thedirectisyns were manufactured by Jet Electronics and Technology, Inc., and were designatedas model no. DN 101D01. They were installed in the nose compartment of the airplane. Bothunits received impact damage but were not burned. Wiring diagrams provided by Learjetindicated that one directisyn provided heading information to the captain’s CDI and thefirst officer’s RMI. The other directisyn provided heading information to the firstofficer’s CDI and the captain’s RMI.

According to maintenance records, the captain’s CDI received heading information fromthe directisyn marked as S/N G1704. An examination of the unit’s electrical power fuserevealed that it was intact and not blown. The power circuit board was extracted andtested, and all output specifications were met. The case surrounding the gyro was cut awayto afford an internal view. The gimbal hardware surrounding the spinning mass assembly wasbent. The bending damage was consistent with the impact marks on the case. The spinningmass assembly was extracted from the directisyn. When electrical power was applied to theassembly, the spinning mass inside the housing began to rotate. Electrical power was thenremoved, and the gyro was disassembled. An examination of the exterior of the spinningmass and the mating surface of the housing revealed distinct rotational score marks, whichwere oriented along the direction of impact damage.

According to maintenance records, the first officer’s CDI received heading informationfrom the directisyn marked as S/N G1562. Examination of the first officer’s directisynrevealed damage similar to that found during examination of the captain’s directisyn.

Navigation Receivers

The airplane was equipped with two Collins VIR-30A analog navigation receivers, oneeach for the captain and first officer positions. The control heads for the units weremounted in the cockpit and were completely consumed by fire. The remote receiver unitswere mounted in the nose compartment and survived the fire, but they did not containnonvolatile electronics or mechanical linkages from which to obtain any informationregarding frequency selection. According to maintenance records, the captain’s CDI and HDIdisplayed navigation information via signals sent from the Collins VIR-30A remote unitmarked as S/N 1672. The maintenance records also showed that the first officer’s CDI andHDI received navigation information from the Collins VIR-30A remote unit marked as S/N12489.

Attempts were made to conduct a bench test of each VIR-30A as a full unit; however,impact damage precluded testing. Both the units were then disassembled, and individualmodules were extracted. The VOR/localizer module on both units was too damaged to betested.

The captain’s glideslope module remained intact. A sampling of glideslope channels wasevaluated for general operation, as characterized by instrument flag position anddeviation response. The evaluation revealed that the receiver provided proper responsesand deviation indications on 20 separate channels but did not provide any response on 10other channels. The non-responsive channels always provided a signal to trip an instrumentnavigation warning flag. According to Collins, this pattern of working and non-workingchannels is consistent with the failure of one or more of the fragile discreet crystalsthat are installed in the unit and used to tune to specific glideslope channels.

The first officer’s glideslope module remained intact. A sampling of glideslopechannels was evaluated. The evaluation revealed that the deviation output resulted in amaximum “fly down” indication regardless of the channel tuned. The glideslopewarning flag operated erratically for most channels evaluated. Additional evaluationrevealed that an operational amplifier, designated as No. A1U202A, had failed. Anexamination of electrical schematics of the glideslope module revealed that the failedamplifier controls the deviation of the glideslope needle and that the amplifier’sfunction occurs downstream of the glideslope flag circuitry.

Collins provided the Safety Board with a VIR-30A repair history. According to Collins,1,336 repair actions on VIR-30A units were recorded between January 1990 and March 1998.Of those repair actions, the A1U202A amplifier was replaced in 12 instances. Of those 12instances, 3 repair action reports cited that the glideslope warning flag came into viewduring the failure, and 6 reports cited a “glideslope deviation problem.”

Organizational And Management Information

According to information provided by American Corporate Aviation, the company has heldan air carrier certificate since 1968, when it commenced operations in Kansas City,Missouri, flying on-demand freight and passengers. By the early 1970s, the company wasoperating as an air ambulance and a scheduled freight carrier for the U.S. Postal Service.The company relocated to Houston in the spring of 1992.

At the time of the accident, American Corporate Aviation was authorized by the FAA toconduct operations under the provisions of 14 CFR Part 135 using the following nineairplane types: Beech King Air E90, Cessna 208B, Cessna 421B, Learjet 25B, Learjet 25D,Learjet 35A, Mitsubishi MU-2B-25, Mitsubishi MU-2B-60, and Gulfstream Commander 681.American Corporate Aviation was also authorized to conduct its operations under thebusiness names of Medical Express International and Royal Jet. According to the CEO ofAmerican Corporate Aviation, Medical Express International is an air ambulance servicewith a business office located in Scottsdale and a base of operations in Show Low,Arizona.

Review of the Safety Board’s accident database indicated that American CorporateAviation experienced one previous accident involving a Rockwell Commander 681 on an airambulance flight on March 12, 1994, at Phoenix, Arizona. The airplane sustainedsubstantial damage during landing with the MLG partially extended. The pilot, two flightnurses, and two passengers were not injured. The Safety Board determined that the probablecause of the accident was “the failure of the hydraulic and nitrogen system pressurelines, due to an inadequate maintenance inspection program, which failed to detect thecorrosion condition of the lines.”

FAA Surveillance

The FAA Flight Standards District Office (FSDO) responsible for surveillance ofAmerican Corporate Aviation is located in Houston. The principal operations inspector(POI) assigned to American Corporate Aviation joined the FAA in 1987 and became a POI in1989. He was assigned to American Corporate Aviation in 1996.

In an interview conducted during the accident investigation, the POI stated that he wasresponsible for approximately 37 to 39 operators. He categorized these operators asfollows: 8 to 9 Part 91 executive operators, 20 Part 135 charter operators, 7 to 8 Part137 agricultural operators, and 2 Part 141 pilot school operators. The POI stated that hewas also responsible for four pilot examiners and one pilot proficiency examiner. The POIsaid that, during an inspection, he “looks at everything but sometimes wonders ifit’s as complete as it should be” because he is “doing essentially a spotcheck.” The POI said that he had accomplished four or five inspections of AmericanCorporate Aviation in the year preceding the accident. During one of these inspections, inJuly 1997, he observed the director of operations give a check ride, which the POI saidwas done “by the book.” The POI stated that he does not have time to sit in ontraining but that he sometimes “sticks his head in.” He also said that it isdifficult to get the opportunity to do en route inspections and that he had never done anen route inspection of American Corporate Aviation.

The FAA’s Program Tracking and Reporting Subsystem showed that FAA inspectors conducteda total of 42 and 51 surveillance activities on American Corporate Aviation in fiscalyears 1996 and 1997, respectively. The system reported a total of 41 surveillanceactivities from October 1, 1997, to January 12, 1998.

Safety Board investigators interviewed the POIs of two other Houston-area 14 CFR Part135 operators: Aviex Jet and Air America Jet Charter. The POI assigned to Aviex Jet statedthat he was responsible for approximately 46 other operators. The POI assigned to AirAmerica Jet Charter stated that he was responsible for a total of 15 operators.

Safety Board investigators also interviewed the Houston FSDO Manager. The managerstated that, at the time of the accident, the FSDO was responsible for surveillance of 57Part 135 operators, 51 Part 137 operators, 7 Part 141 operators, 5 Part 133 operators, 175Part 91 executive operators, and 37 pilot proficiency and pilot examiners. According tothe manager, the workload of the FSDO, which she characterized as “heavy,” wasabout the same as that of the FSDOs in San Antonio, Texas, and Indianapolis, Indiana.

Additional Information

The Flight Operator

The charter flight to take five Paracelsus HealthCare Corporation executives fromHouston to Fargo was originally scheduled to be flown by Executive Air Charter of Houston.In an interview conducted during the accident investigation, the Director of Operationsfor Executive Air Charter stated that, as the date of the flight neared, the companyrealized that it would not have an airplane available to operate the flight. The directorof operations further stated that the captain of the accident flight suggested that hecall the Director of Operations for American Corporate Aviation. Executive Air Charter’sDirector of Operations said that “the trip was accepted [by American CorporateAviation], and it was decided that Executive Air Charter would collect payment for theflight.”

In an interview conducted during the accident investigation, the Director of Operationsfor American Corporate Aviation stated that Executive Air Charter brokered the accidentflight. In a February 4, 1998, letter to the CEO of American Corporate Aviation, thedirector of operations reported that the captain had contacted him in January 1998 aboutusing N627WS. The director of operations further reported that he advised the captain thathe “did not have dispatch authority” and directed him to call the CEO ofAmerican Corporate Aviation. According to the letter, the CEO later contacted the directorof operations and told him that he “had given authority for the trip” inexchange for time in another Learjet.

In an interview conducted during the accident investigation, the CEO of AmericanCorporate Aviation stated that he received a call from the captain, requesting the use ofN627WS for a trip to Fargo on January 13. The CEO further stated that he”assumed” the trip was a 14 CFR Part 91 flight for Linrose Aviation because he”knew” the captain worked for Linrose Aviation. The CEO said that he proposedtrading the flight time on the Fargo trip for future flight time on Linrose Aviation’sLearjet. (The Linrose Learjet, N245BS, was authorized for use under the 14 CFR Part 135operations specifications of American Corporate Aviation.) Additionally, the CEO statedthat he approved the flight but that, if he had known that the trip was for Executive AirCharter, he would never have approved it without getting paid in advance.

In an April 10, 1998, letter to the Safety Board investigator-in-charge, the CEO ofAmerican Corporate Aviation wrote that, when the captain called him to request the use ofN627WS, the captain “introduced himself” as a pilot for Linrose Aviation andexplained that the Linrose Learjet “was unavailable.” The CEO further wrote that”[the captain] and others used fraud and misrepresentation for their financial gainto cause me to release Lear N627WS for their use on January 13, 1998.” The letterconcluded with a statement indicating that the CEO did not believe American CorporateAviation should be considered the operator of the flight. The CEO reiterated this positionin a November 12, 1998, letter to the investigator-in-charge.

American Corporate Aviation’s Flight Dispatching

Under the heading “Flight Dispatching,” page 9.5 of American CorporateAviation’s Operations Manual, dated December 31, 1995, stated that “the Director ofOperations will be responsible for dispatching flights.” This section of the manualalso listed three other individuals who were “authorized to act as operations managerand be responsible for dispatching flights.” One of the listed individuals was theCEO of American Corporate Aviation.

The specific duties of the director of operations were listed in the Operations Manualon page 8.3, dated February 8, 1994, under the heading “Director of Operations -Duties and Responsibilities.” Two of the listed duties stated, “schedulesaircraft to available flight crew members and establishes personnel duty hours” and”schedules aircraft into applicable inspections and maintenance and coordinates allflights.”

American Corporate Aviation’s Approach Procedures The Crew Coordination Proceduressection of American Corporate Aviation’s Training Manual, which was dated February 15,1992, contained “procedures to be used by the crew which are in addition to thenormal checklist.” Under the heading “APPROACH,” the following items werelisted:


  1. Sets Navigational Radios To Proper Frequencies And Bearings

  2. Gives Co-Pilot The Final Approach Briefing


  1. Reviews Approach After The Captain Gives Final Briefing

  2. Before Landing Briefing To Passengers

  3. On Step Down Approaches Calls Out The Next Altitude After Leaving The Previous Altitude, On ILS, Calls Glide Slope Intercept

  4. Calls 1,000 Ft To Go to Missed Approach or MDA [minimum descent altitude]

  5. Calls 500 Ft To Go and Every 100 Ft Thereafter Until Reaching MDA or Missed Approach Point

  6. Calls Missed Approach Point

  7. Calls Runway In Sight

Ground Proximity Warning System

N627WS was not equipped with a Ground Proximity Warning System (GPWS), and none wasrequired under 14 CFR Part 91 or 135. According to data supplied by a U.S. manufacturer ofGPWS equipment, the flight profile of the accident airplane indicated that a mode 5,Descent Below Glideslope, aural warning would have sounded approximately 40 seconds beforeinitial impact at an altitude of 1,100 feet msl. Two additional mode 5 warnings would havesounded approximately 34 and 14 seconds before impact. A mode 1, Excessive Sink Rate,aural warning would have sounded approximately 11 seconds before impact at an altitude of600 feet msl and continued to the end of the flight.

Minimum Safe Altitude Warning

IAH TRACON is equipped with an Automated Radar Tracking System (ARTS) IIIA radar dataprocessing system, which includes Minimum Safe Altitude Warning (MSAW) software to monitoraircraft separation from terrain and obstacles. MSAW provides air traffic controllers withboth a visual alarm indication and an aural tone if an aircraft is below or predicted todescend below a prescribed minimum altitude. These minimum altitudes vary according togeographic location and the type of flight operation being conducted.

For ARTS IIIA systems, MSAW configuration data is found in “Minimum Safe AltitudeWarning,” National Airspace System document no. MD-633. MSAW operates in three modes:general terrain monitoring, approach path monitoring, and satellite airport monitoring.General terrain monitoring services are provided to aircraft not imminently arriving to ordeparting from primary or satellite airports. Satellite airport monitoring is applied toaircraft operating in the vicinity of airports other than the airport adapted as”primary” in the ARTS software (in this case, IAH). Because of its position,heading, and status as an IAH arrival, N627WS was subject to approach path monitoring atthe time of the accident.

The approach path monitor defines a rectangular area along the final approach course.Aircraft within the area are monitored based on a comparison between their current Mode Creported altitude and a specified minimum altitude. The alert threshold altitude iscalculated by subtracting the airport elevation plus a 100-foot buffer from the lowestnon-precision MDA for instrument approaches to the specified runway. If an aircraft is inthe monitor area and above the alert threshold, its altitude is extrapolated 15 secondsahead and compared with the alert threshold. If the aircraft is predicted to be below thethreshold altitude on two consecutive scans, an approach warning is declared.

For IAH runway 26, the monitor area extended from the final approach fix to a point 2nm from the runway threshold and 1 nm left and right of the centerline. At the time of theaccident, the IAH runway 26 alert threshold was set to 100 feet agl. This computation wasbased on subtracting 100 feet from the decision height for the ILS 26 approach (200 feetagl). No alerts were generated during either approach of N627WS.

After the accident, FAA personnel recalculated the MSAW parameters for all IAH runways.The lowest non-precision MDA for runway 26 is 600 feet msl, found on the GPS 26 procedure.The new alert threshold altitude calculated for runway 26 is 500 feet msl, or 402 feetagl.

At the request of the Safety Board, the FAA Technical Center configured its ARTS IIIAtest and development system to emulate the IAH ARTS, using both the old and new MSAWparameters. Data from N627WS were reprocessed using ARTS “Retrack” software,which permits examination of system performance using archived radar data. The last fiveobserved target times and altitudes shown by “Retrack” were as follows:

  • 0809:29.943 and 800 feet msl,

  • 0809:34.565 and 700 feet msl,

  • 0809:39.183 and 700 feet msl,

  • 0809:43.750 and 500 feet msl, and

  • 0809:48.402 and 400 feet msl.

With the original MSAW adaptation, the N627WS flight path generated no alerts. With thenew parameters, MSAW alerts were displayed from 0809:50 to 0809:59. A single predictedalert occurred at 0809:27.389, but the alert would not have been displayed to controllersbecause it was not repeated on the next consecutive scan.