Why On-Demand Jet Charter Needs CRM... Now!

Submitted September, 2002

The NTSB Trigger Event
Overview
Management Oversight
Operations Manual
Regulatory Requirements
The Approach
Conclusion
References

Gulfstream III Crash
Aspen, Colorado. March 29, 2001

The NTSB Trigger Event

On March 29th, 2001, about 1902 Mountain Standard Time (MST)1, 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, Colorado. 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, California, to ASE.

The following is a reprint of an NTSB Safety Recommendation. It was dated June 13th, 2002, addressed to Jane Garvey (FAA Administrator at the time) from Marion Blakey (NTSB Chairman at the time).

Background

N303GA departed LAX about 1611 Pacific Standard Time (1711 MST) and entered the Aspen terminal area about 1843.[2] According to the cockpit voice recorder (CVR) recording, the flight crew had been planning a visual approach to runway 15; however, as the airplane descended toward the airport, clouds and snow showers increased, obscuring the field. The automatic terminal information service information in effect during the final approach indicated that the weather conditions were wind 250º at 3 knots; visibility 10 miles; light snow; few clouds at 1,500 feet; broken cloud ceiling at 2,500 feet; and broken cloud ceiling at 5,000 feet. As N303GA continued toward the airport, ASE air traffic controllers provided arriving airplanes with vectors for the VOR/DME-C instrument approach procedure to the airport.[3] About 1845, the crew of a Canadair Challenger 600, N527JA, executed a missed approach because of limited visibility. About 1853, another Canadair Challenger 600, N898R, also executed a missed approach. About 1856, the accident airplane was cleared for the VOR/DME-C approach course, and the captain was notified that visibility north of the airport was reduced to 2 miles. About 1858, N527JA executed another missed approach because the captain could not see the airport. At 1900:27, after the airplane had passed the final approach fix, the captain of N303GAasked the local controller, “are the runway lights all the way up?” The local controller stated,” affirmative they’re on high.” At 1900:43, the captain asked the first officer, “you see the runway,” and, at 1900:46, “you see the highway?”[4] At 1900:49, the Aspen local controller asked the flight crew of N303GA, “you have the runway in sight?”[5] At 1900:51, the first officer stated, “affirmative,” and, at 1900:52, he transmitted to the controller, “runway in sight.”[6] According to the controller, less than 1 minute later, she observed N303GA emerging from a snow shower at a low altitude and not aligned with the runway. Radar data show that about this time, the airplane started maneuvering to the runway, entering a steep left turn for final runway alignment. While in this turn, the airplane impacted terrain to the right of the extended runway centerline, 100 feet above the runway 15 threshold elevation and 2,400 feet short of runway 15. The approach end of runway 15 is at an elevation of 7,674 feet mean sea level (msl), and the opposite end of the runway is at an elevation of 7,815 feet msl, resulting in an upward slope.

Flight Crew Coordination

The Avjet Operations Manual in effect at the time of the accident was dated July 15, 2000. 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; MDA; visual descent point; circling maneuver; missed approach heading, altitude, and intentions;[7] runway information; and abnormal conditions. Although the CVR recorded the captain briefing a visual approach, the CVR did not record the captain briefing the instrument approach procedure or any of the instrument approach briefing information required by Avjet. Pages 4-4 and 4-5 of Avjet’s Operations Manual 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 after the decision height or missed approach point (MAP). The first officer is responsible for several callouts, including the following:

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.”

Therefore, when the airplane reached altitudes of 11,200, 10,700, and 10,300 feet, Avjet’s Operations Manual required the first officer to call out, “1000 to go [until landing minimums],” “500 to go,” and “approaching minimums,” respectively. However, the CVR did not record him making any of these callouts.[8] According to an airplane performance study conducted by the Safety Board, at 1900:39,the airplane leveled off at an altitude of 10,100 feet, 300 feet below the minimum specified altitude required for the airplane’s position at the time. Further, as noted previously, at 1900:46 (about the time the captain was asking the first officer if he had the highway in sight), N303GAhad descended about 200 feet below the MDA, and, at 1900:52 (about the time the first officer responded to the Aspen tower controller that he had the runway in sight),[9] it had descended about 450 feet below the MDA. The first officer should have called out these deviations to the captain, but the CVR did not record him making these callouts or challenging the captain about operation of the airplane below the MDA, and radar data indicated that the captain did not correct the descent. At 1901:21, when N303GA was about 900 feet above the airport elevation, the CVR recorded a configuration deviation warning that lasted for 9 seconds. This warning indicated that the captain had deployed the spoilers after the landing gear had been extended and landing flaps selected in the full-down position (39°), which is prohibited by the FAA-approved aircraft flight manual (AFM).[10] Further, when the captain deployed the spoilers, the engine power was set to about 55 percent N2.[11] The AFM states that the minimum engine power setting on final approach should be 64 percent N2.[12] CVR evidence indicated that the captain did not include the first officer in his decision-making process regarding spoiler deployment and power setting and that the first officer did not question or challenge the captain about either item.[13] At 1901:36, N303GA passed the MAP about 485 feet above field elevation rather than the specified 2,385 feet. The first officer was required to call out, “missed approach point, runway in sight,” or “missed approach point, runway not in sight,” and the captain was required to announce his intentions. However, the CVR did not record either of these callouts or any evidence that the captain or the first officer understood that they were flying at too low an altitude. About the same time as the airplane passed the MAP, the captain asked, “where’s it at? “This statement suggests that the captain had not identified, or had lost visual contact with, the runway. At this point, the captain should have abandoned the approach or the first officer should have called for a go-around, especially because the airplane was close to the ground in mountainous terrain. The first officer stated, “to the right,” about 6 seconds after the captain’s query. Even if the first officer did in fact have the runway in sight at this point, the captain, as the flying pilot, should not have been relying on the first officer for directional guidance during the visual transition from the instrument approach to the landing. Conversations recorded by the CVR during the last 2 minutes of flight suggest that the flight crew was preoccupied with looking outside the cockpit in an attempt to visually locate the airport. As a result, the captain continued flight below the authorized MDA after failing to establish or maintain visual contact with the runway. The first officer did not challenge the captain’s actions.[14]

Crew Resource Management Training and Regulatory Guidance

Crew resource management (CRM) training, which focuses on interpersonal skills, leadership style, communication, crew coordination, planning, briefing, workload management, decision-making, error management, risk identification, and management techniques in the cockpit, was developed by the National Aeronautics and Space Administration between themid-1970s and early 1980s [15] to integrate human factors concepts into flight crew training. CRM training was developed in response to several Safety Board investigations of flight crew-related aircraft accidents[16] and statistical data that indicated that a large percentage of air carrier accidents are flight crew related. Most air carriers have several days of dedicated CRM training at which accidents are reviewed and, in some cases, pilots examine their own communication styles to determine specific strengths and weaknesses that may affect crew coordination in the cockpit. These courses also allow participants to interact with each other, obtain feedback, role-play, learn strategies to improve workload and error management, recognize leadership qualities, and reinforce effective attitudes and behavior.

As part of a 1994 safety study, the Safety Board issued Safety Recommendation A-94-196, which recommended that the FAA “revise within 1 year the pilot training requirements for scheduled Part 135 operators such that: all pilots are provided mandatory crew resource management training that incorporates the principal components of effective CRM training.”[17] In response to this recommendation, on December 20, 1995, the FAA issued the final rule titled, “Air Carrier and Commercial Operator Training Programs,” which established a requirement that, after March 19, 1997, 14 CFR Part 135 commuter operators that conduct scheduled operations with aircraft requiring 2 pilots or that have 10 or more passenger seats must establish, among other things, an FAA-approved CRM training program for its pilots in accordance with 14 CFR Part 121, subparts N and O.[18] However, because this requirement did not extend to Part 135 on-demand charter operators, Avjet was not required to establish an FAA-approved CRM training program for its pilots.[19] The cockpit environments and the duties of multi person flight crews of Part 135 on-demand charter operations are similar to those of Part 135 commuter operations. Further, many Part 135 on-demand charter operators use sophisticated turbojet and turboprop equipment and can be affected by operational demands similar to those experienced by Part 135 commuter operators (such as, schedule pressure and customer needs), which may influence the aeronautical decision-making process. The evidence from this investigation has shown that the accident flight crew exercised poor CRM in the following ways: (1) the captain did not brief the instrument and missed approach procedures or any other required information, (2) the flight crew did not make required instrument approach callouts, (3) the captain did not include the first officer in the aeronautical decision-making process, and (4) the first officer did not question or challenge the captain or intervene when he placed the airplane in a potentially unsafe flying condition. The Safety Board is concerned that Part 135 on-demand charter operators, such as Avjet, and other operators that conduct operations with aircraft requiring two or more pilots do not need to meet the CRM training requirements outlined for Part 135 commuter operators.

June 13, 2002 NTSB Recommendation

Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: Revise 14 Code of Federal Regulations (CFR) Part 135 to require on-demand charter operators that conduct operations with aircraft requiring two or more pilots to establish a Federal Aviation Administration-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. (A-02-12)

Chairman BLAKEY, Vice Chairman CARMODY, and Members HAMMERSCHMIDT,

GOGLIA, and BLACK concurred in this recommendation.
By: Marion C. Blakey

Chairman
Original Signed

1 Unless otherwise noted, all times in this letter are MST, based on a 24-hour clock.

2 There were no reports from the airplane or air traffic control (ATC) of any abnormalities during the en route portion of the flight

3 VOR/DME stands for very high frequency omnidirectional radio range/distance-measuring equipment. The “C” in the approach title indicates that the approach does not include straight-in landing minimums because it does not meet the criteria for course alignment and/or the maximum descent gradient.

4 During the approach, the highway was located slightly to the right of the extended runway centerline. Radar data indicate that about this time, N303GA descended about 200 feet below the minimum descent altitude (MDA) depicted on the approach chart for its position.

5 According to post accident interview statements, ASE controllers are trained to closely monitor the progress of airplanes executing the VOR/DME-C approach and to immediately advise a pilot if his or her aircraft passes below are required minimum altitude. Most controllers reported that, if they observe an aircraft’s altitude to be about 200 feet lower than published minimums, they will ask the pilot if the runway is in sight.

6 Radar data indicate that about this time, N303GA was about 450 feet below the MDA depicted on the approach chart for its position.

7 Early in the CVR recording, the captain discussed the possibility that the airplane might have to go to an alternate airport because of a landing restriction that required the airplane to land within a 1/2 hour after sunset at ASE. Because the airplane departed LAX 41 minutes later than scheduled (due to the late arrival of passengers) and, as a result, was estimated to arrive at ASE about 12 minutes before the curfew, the captain should have included a missed approach briefing.

8 The first officer was also required to call out course, fix, and altimeter information, but the CVR did not record him making any of these callouts.

9 Evidence suggested, however, that the flight crew did not actually have the runway in sight or had it in sight at that point only briefly. Specifically, the CVR did not record any previous independent indication from either flight crewmember that he had visually identified the runway. Also, the CVR did not record any further discussion throughout the rest of the flight that would be consistent with a flight crew that could see a runway.

10 Spoilers are extendable panels located on top of the wings that are deployed to decrease the speed of the airplane or increase its rate of descent. It is likely that the captain deployed the spoilers on short final in an attempt to increase the airplane’s rate of descent to get below the local snow showers and visually locate the runway.

11 N2 is the rotational speed of the high-pressure spool in a gas turbine engine.

12 Sixty-four percent N2 allows for minimum engine spool-up time in the event of a missed approach.

13 The deployment of the spoilers at the incorrect power setting for final approach placed the airplane in a potentially unsafe and destabilized condition.

14 A 1994 safety study noted that a crewmember’s failure to monitor or challenge another crewmember’s error was a common causal or contributing factor in major flight crew-related accidents. For more information, see National Transportation Safety Board. 1994. A Review of Flightcrew-involved Major Accidents of U.S. Carriers 1978through 1990. Safety Study. NTSB/SS-94/01. Washington, DC.

15 At that time, CRM was referred to as “cockpit resource management.”

16 For example, see National Transportation Safety Board. 1973. Eastern Air Lines, L-1011, N310EA, Miami, Florida, December 29, 1972. Aircraft Accident Report. NTSB/AAR-73/13. Washington, DC; National Transportation Safety Board. 1979. United Airlines, Inc., McDonnell Douglas, DC-8-61, B8082U, Portland, Oregon, December 28, 1978. Aircraft Accident Report. NTSB/AAR-79/07. Washington, DC; and National Transportation Safety Board. 1982. Air Florida, Inc., Boeing 737-222, N62AF, Collision with 14th Street Bridge, Near Washington National Airport, Washington, DC, January 13, 1982. Aircraft Accident Report.NTSB/AAR-82/08. Washington, DC.

17 For more information, see National Transportation Safety Board. 1994. Commuter Airline Safety. Safety Study.NTSB/SS-94/02. Washington, DC. This was not the first time that the Safety Board issued recommendations to the FAA regarding CRM. For example, in response to the October 28, 1989, Aloha Island Air accident, the Board issued Safety Recommendation A-90-135, which asked the FAA to “require that scheduled 14 CFR Part 135 operators develop and use cockpit resource management programs in their training methodology by a specified date.” On July 15, 1996, the Board classified Safety Recommendation A-90-135 “Closed—Acceptable Action.”

18 On July 15, 1996, the Safety Board classified Safety Recommendation A-94-196 “Closed—Acceptable Action” based on the issuance of this rule.

19 Appendix C of the Avjet Training Manual, pages C-56 and C-58, indicates that CRM is 1 of 13 general

operational subjects addressed during Gulfstream G1159 series initial and recurrent ground training. The manual did not indicate any stand-alone CRM module or formal classroom instruction on CRM, which is required for Part 121CRM training.

- Conclusion of NTSB reprint -

Overview

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 a FAA-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. This, in light of the tragic Gulfstream III accident in Aspen Colorado in 2001, where there was such a breakdown in communications, responsibilities, and procedures between the crewmembers, that 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 Figure 1 below. This is a line-by-line comparison of accidents per 100,000 flight hours for all types of aviation operations:

Accidents Per 100,000 Flight Hours, 1987-1998

Source: NBAA

Type of Operation Accidents

Part 91 Fractional Business Jets	0.174
Part 91 Corporate/Professionally-Flown Business Jets	0.188
Part 121 Scheduled Air Carriers	0.229
Part 91 Corporate/Professionally-Flown Aircraft (all a/c)	0.241
Part 121 Non-Scheduled Air Carriers	0.423
Part 135 Scheduled Commuters	0.925
Part 135 On-Demand Jet Charter	1.960

Figure 1

Crew Resource Management, formerly known as Cockpit Resource Management, has its roots at United Airlines, 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, Colorado accident will be used as a “classic case” scenario in which the breakdown of flightcrew 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.

Management Oversight

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:

“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.

Operations Manual

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, SOP’s (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."

Regulatory Requirements

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 Approach

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 captains 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 Flightsafety 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

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 jumpseat, especially if it were the charter customer, most likely further heightened the pressure on the flight crew to land at ASE.

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.

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.

Conclusions

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 flightcrew.
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.

References

Wiener, Earl L, and Nagel, David C (1988) Human Factors in Aviation: Human Error in Aviation Operations pp. 263-301.

Flightsafety Foundation Digest. (August-September 2001 Issue). International Organizations Rise to Challenge to Prevent Approach and Landing Accidents.

National Business Aviation Association Website (2003). www.nbaa.org Aviation Safety Statistics. Washington DC.

Federal Aviation Administration Website (2003). www.faa.gov Various Data Washington, DC.

National Transportation Safety Board Website (2002). www.ntsb.gov. Aircraft Accident Brief. File # DCA01MA034. Washington, DC.

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