- 2 days ago
Air Crash Investigation - Season 26 Episode 1 - Norwegian Nightmare WiderøE Flight 839
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Short filmTranscript
00:01A private charter jet is flying 15 passengers to Aspen, Colorado for a party.
00:07This flight really captured the public attention because of the people on board.
00:13Poor weather makes the landing a challenge for the experienced pilots.
00:18Can you see out there at all yet?
00:20No.
00:21Aspen is considered one of the most dangerous airports in the country.
00:25As the plane nears the runway, the controller watches as disaster unfolds.
00:31What are they doing?
00:38Investigators examine the Gulf Stream's wreckage for answers.
00:42I don't see any issues here.
00:45When they learn about the passengers' behavior...
00:48We're running out of fuel here for the birthday boy!
00:52The moving parts of this mystery fall into place.
00:55That clearly had to put some pressure on the pilots to say,
00:58all right, this is not looking good.
01:02D-D, D-D.
01:06Oh, fuck.
01:09I need one, two, three, four.
01:10I need one, two.
01:11I need one, two.
01:12I need one, two.
01:13I need one, two.
01:14I need one, two.
01:15I need one, two.
01:16I need one, two.
01:17I need one, two.
01:18I need one, two.
01:19The sun has just set over the Colorado mountains.
01:28Avjet November 303 Gulf Alpha is nearing the end of its journey to Aspen.
01:34Well, there's the edge of the night there.
01:38Yeah.
01:40Captain Robert Frisbee has almost 10,000 flying hours to his credit.
01:44What time is official sunset?
01:49He and First Officer Peter Kowalczyk have been flying together for close to five months.
01:55628.
01:59Both pilots have been with Avjet for less than a year.
02:04The small charter airline is based out of Burbank, California.
02:07Amjet catered to high rollers, business people, people who could afford to charter a jet.
02:16People who had to get there in a hurry, but do it in style.
02:21Running out of fuel here for the birthday boy.
02:26A Miami financier chartered this flight for 14 of his friends to attend a birthday party at an exclusive venue in Aspen.
02:34This was a group of friends who seemed to have had tremendous early achievements and accomplishments, and they were really going to go places.
02:47So 4,800 pounds, 126.
02:49It was 50.
02:51You know what? I adjusted it, because the fuel was way off.
02:55The pilots are flying a Gulf Stream 3.
02:58The Gulf Stream is a luxurious plane that, you know, people see in the movies and people think high rollers and movie stars flying.
03:10But it's a workhorse plane. It actually has a good reputation.
03:12It's a 90-minute flight from Los Angeles to Aspen.
03:15Gulf Stream 3.03 Gulf Alpha, Aspen, reduced speed to 210 or slower.
03:29The controller slows down the Gulf Stream to maintain a safe distance from the other planes heading into Aspen.
03:352-1-0 or slower, 3 Gulf Alpha.
03:44Seventeen minutes from landing, the pilots begin their descent.
03:49Aspen-Pitkin County Airport, also known as Sardi Field, is about three miles northwest of Aspen.
03:57Landing on its single runway is a challenge.
04:03Aspen is considered one of the most dangerous airports in the country.
04:08The runway is not long, and it is in close proximity to high terrain on all sides.
04:16Hey, do you remember that crazy guy in the Lear when we were in Aspen last time?
04:23It was, I can see the airport.
04:26But he couldn't see it.
04:30Set you up on the approach.
04:32The landing is made even more difficult, with the final stage needing to be carried out visually.
04:38As the plane nears Aspen, a beacon guides it to the airport.
04:44But it doesn't lead it directly to the runway.
04:47Once the airport is in sight, the pilots must line up with the runway visually.
04:52Because of the high terrain and close proximity to the final approach course, the minimum altitude is a couple thousand feet above the ground.
05:01And we must be visual by that time to safely continue our descent down to a landing.
05:08And tonight, the weather isn't making landing any easier.
05:12And if at any time it's snowing, it's very hard to acquire that visual reference to safely descend further to a landing.
05:27Residential noise restrictions around the airport leave the pilots only nine minutes until the landing curfew at 6.58.
05:36The crew is cutting it close.
05:40Can you see out there at all yet?
05:43Uh...
05:45No.
05:49Kofstream 3 Gulf Alpha, heading 050.
05:53Heading 050, 3 Gulf Alpha.
05:58As the pilots prepare to line up with the runway, passengers get ready for landing.
06:03Synchronizer's off.
06:04There is just enough fuel for one landing attempt. After that, the pilots will have to divert to another airport.
06:20Okay, it's off.
06:21Hydraulic pressure's good.
06:22Gulfstream 3 Gulf Alpha, turn heading 1-4-0. Intercept final approach course. Maintain 1-6-thousand.
06:34Eight minutes from the airport, the controller gives the crew clearance to commence the approach.
06:411-4-0, 1-6-thousand. Intercept final approach course 3 Gulf Alpha.
06:461-6-thousand.
06:471-6-thousand.
06:48As the pilots get their final intercept to the airport.
07:02Challenger 7, Juliet Alpha, you have the airport in sight.
07:06Another aircraft, also on approach to Aspen, updates the controller.
07:11That's a negative. Going around.
07:14Those pilots aboard their landing, because they can't see the runway.
07:22Attention all aircraft. Last aircraft went missed.
07:26What?
07:27Went missed.
07:29Went missed? Damn.
07:32That's not good.
07:34If you can't successfully land the aircraft, then a missed approach is a procedure that pilots will execute
07:41to return to a safe altitude.
07:45As the Gulfstream gets closer to the airport, the weather deteriorates.
07:59Gulfstream 3 Gulf Alpha, 5 miles from Red Table, cross Red Table at or above 1-4-thousand.
08:06Clear VOR DME Charlie approach.
08:07The controller clears the pilots to begin the final approach, 11 miles from the airport.
08:17You have to be configured properly at the right altitude at the right speed.
08:22Otherwise, you are expected to execute a missed approach.
08:26Red Table at 1-4-thousand. Cleared for VOR approach. Gulfstream 303 Gulf Alpha.
08:33Here we go.
08:35As the pilots get closer to the airport, they're counting on the weather to improve for their landing.
08:43Resetting to 1-4-thousand.
08:46Problems can escalate very quickly when flying into Aspen.
08:51There's really no room to recover without breaking off that approach or trying it again.
08:59Landing flaps.
09:02Landing flaps.
09:04Just over two minutes from landing, instruments have successfully guided the pilots to the airport.
09:09Now it's up to them to identify the runway.
09:13You see the runway?
09:16Gulfstream 3 Gulf Alpha, you have the runway in sight?
09:23Affirmative.
09:24Yeah, now we do.
09:25Runway in sight, 3 Gulf Alpha.
09:26Gulfstream 3 Gulf Alpha, visual.
09:27Roger.
09:281,000?
09:291,000 to go.
09:30The pilots are now less than a minute from landing.
09:31200.
09:32At the last moment, they realize something is wrong.
09:33Go!
09:34Go!
09:35Go!
09:36Go!
09:37Go!
09:38Go!
09:39Go!
09:40Go!
09:41Go!
09:42Go!
09:44Go!
09:45Go!
09:47Go!
09:48Go!
09:49Go!
09:51Go!
09:52Go!
09:54part the last moment they realize something is wrong.
09:57Go!
09:59Go!
10:00Go!
10:01Go!
10:04The pilots are now less than a minute from landing.
10:05Avjet 303 Gulf Alpha crashes just short of the runway at Aspen.
10:23Aircraft identification Gulfstream 303 Gulf Alpha.
10:27Aircraft location, it was north of the runway, approximately the Shale Bluffs area.
10:32Emergency vehicles rush to the scene in the hope that there are survivors of the crash of Avjet 303 Gulf Alpha.
10:51But all 18 people on board are dead.
10:54All 15 passengers, the two pilots and the flight attendant.
11:02This flight really captured the media and the public attention because of the people on board.
11:14There were a lot of very young, talented people.
11:18Put everything from the tail section over there.
11:27By the following day, investigators are on site.
11:33Thousands of passengers fly charter airplanes every year, encompassing 2.5 million flight hours annually.
11:42So trying to understand why this accident occurred was significant.
11:52Let me see that.
11:54Within hours, the plane's cockpit voice recorder, or CVR, is retrieved from the wreckage.
12:00Let's get the data pulled from that ASAP.
12:04What about a flight data recorder?
12:11Looks like there wasn't one.
12:14Okay.
12:17Because the airplane was manufactured in 1980 and registered in 1981, it was not required to have an FDR.
12:25While the CVR is sent for analysis, investigators from the National Transportation Safety Board wonder why the pilots weren't able to land safely.
12:35The plane crashed 2,400 feet from the runway.
12:40When an aircraft crashes short of a runway, especially a sophisticated airplane like a Gulfstream jet, a number of questions arise here.
12:47How did they get there?
12:48What possible factors could the crew have?
12:51Was there some sort of a failure in the aircraft?
12:54What do you think caused that?
13:00There's a deep ground scar at the crash site.
13:06That would do it.
13:09Investigators conclude that it was formed when the left wing hit the ground.
13:13When an airplane comes through trees or vegetation as it approaches the ground, it cuts off branches.
13:22And we can look at those branches and the angles that are made to understand the airplane's attitude as it came into the ground and its descent profile.
13:33Left wing struck the trees at about 49 degrees.
13:42That's a hell of a bank.
13:44There's no operationally relevant reason for an airplane to be banked at 49 degrees that close to the airport or that close to the ground.
13:59Maybe they lost control of the plane.
14:01When we see an aircraft in an abnormal attitude, we've got to look at did something happen where, you know, the pilots couldn't keep it level.
14:12The plane's position gives investigators a promising lead.
14:16Engine failure?
14:17The loss of thrust resulting from an engine failure on one side can yaw the airplane, and if not appropriately managed by the pilots in a timely fashion, can lead to a loss of control.
14:34Aside from the impact damage, there's no sign of fire to the exterior.
14:38The team studies the engine's compressor blades to determine if the engines were functioning when the plane hit the ground.
14:48When the Gulfstream 3's engines are working, the compressor blades spin in a clockwise direction.
14:55If the engines were still functioning when the plane crashed, these blades would be bent counterclockwise or in the opposite direction.
15:02You know, these are all bent counterclockwise, so it wasn't an engine failure.
15:13Our examination of the engines showed that there was no pre-existing damage, no evidence of an in-flight fire, and also showed that they were operating normally and at high power at the time of the impact.
15:28Let's take a look at the rudder.
15:29An airplane operating at a low airspeed while the rudder moves to an extreme limit could introduce a rolling moment or also stall one of the wings, which would further exacerbate the rolling moment.
15:48Investigators examine the actuator that controls the rudder's movement.
15:52The piston is completely intact.
15:56No sign of any damage.
15:59There was no pre-existing conditions or failures that would have explained the accident. The airplane was functioning normally.
16:09If mechanical failure didn't cause the roll, what went wrong on approach?
16:15Determining the airplane's flight path helps us understand how that airplane got to the accident site.
16:22What was it doing? Where was it flying? How fast was it going?
16:28Have a look at this radar data.
16:30With no flight data recorder, investigators turn to Aspen's radar information to reconstruct the Gulf Stream's descent profile.
16:41Using the radar position and time, so the altitude and position of the aircraft, the performance engineers can extract the speed of the aircraft.
16:53How fast is it descending? Is that appropriate for the approach that they're trying to do?
16:58Here's what we've got.
16:59Here's what we've got.
17:03This is the approach they should have flown.
17:07Investigators examine the path the pilots were required to follow into Aspen.
17:11Due to the rising terrain away from the airport, Aspen at this time had a step-down approach, which, from a profile, looks like stairs.
17:24The pilots will step down to an altitude based on the terrain availability.
17:30Pilots cannot descend below that altitude until they reach another fix or another distance.
17:36And here's the descent the pilots actually flew.
17:44The radar data shows the Avjet flight deviated from the published descent profile.
17:51Four miles out, they dropped 300 feet below the minimum.
17:55And a mile later, they dropped 900 feet below the minimum altitude.
18:00And they stayed that way.
18:02They flew in very low.
18:06If you go below a minimum altitude before you are allowed to, then you no longer can guarantee the safety of that aircraft.
18:22Why would they do that?
18:25Because the pilots did not fly this approach to standards, we wanted to look into their backgrounds and training to better understand why the accident may have occurred.
18:36Why did the pilots of Avjet 303 Gulf Alpha not follow the prescribed approach procedure into Aspen?
18:50The captain passed his last proficiency check.
18:53So did the first officer, just a couple months ago.
18:58Investigators learn that all Avjet pilots are trained to land in mountainous terrain like Aspen.
19:04And they both flew into Aspen together twice before, without incident.
19:11No accidents.
19:13No reprimands.
19:16Even the captain's driving record is spotless.
19:18So looking into the background of this flight crew, we really didn't see anything that stood out.
19:25They were both well-qualified, well-trained, and experienced to fly this airplane and make this trip.
19:31And they both got plenty of sleep before the flight, so fatigue isn't an issue.
19:36In fact, I don't see any issues here.
19:38This doesn't make any sense.
19:46Why would two well-trained pilots fly so recklessly below the limits?
19:49No matter whether you're a charter pilot or an airline pilot or even just a personal general aviation pilot,
19:59you know, our number one job is safety.
20:01Regulations are there for a reason.
20:04What is it that could lead a good flight crew to go beyond those safety limits?
20:09Okay, so we know the pilots landed at Aspen twice before with that incident.
20:17What was different this time?
20:21Maybe they were trying to get eyes on the runway?
20:25Pull up the weather.
20:26It was important to understand exactly what was going on with the weather in terms of the layers of clouds,
20:43whether they were solid or broken,
20:45to understand what capability these pilots may have had to see objects on the ground.
20:53The crash was at 7.02 p.m.
20:55Back it up to about 6.30 p.m.
21:00They would have been flying in and out of some pretty heavy cloud here,
21:03so maybe they didn't have a clear line on the runway.
21:08Okay, but these are seasoned pilots.
21:10They should know if you don't see the runway.
21:12You don't try to land on it.
21:13And yet they did try to land on it.
21:14And they missed by almost half a mile, so did they see the runway or not?
21:21We should talk to the controller.
21:25An air traffic controller can tell you what the visibility is, what the weather conditions were,
21:33what other airplanes were doing in terms of coming into the airport,
21:37and provide eyewitness testimony about the time of the accident.
21:41But they also can help us understand communications that they had with the airplane.
21:46So did they give you any indication at all that they were having trouble seeing the runway?
21:54No, quite the opposite.
21:56I asked them if they could see the runway, and they confirmed that they did.
22:00Gulfstream 3 Gulf Alpha, you have the runway in sight?
22:04Yeah, runway in sight 3 Gulf Alpha.
22:07Gulfstream 3 Gulf Alpha, visual. Roger.
22:09I made extra sure to confirm, because I couldn't see them.
22:18The weather was so bad.
22:20Did you have any reason to doubt the pilots?
22:24Not at the time.
22:26But here's what's so odd.
22:29They confirmed they had visual, but then when they came out of the clouds,
22:33they were headed to the right of the airport.
22:35What are they doing?
22:55I don't think they realized they weren't headed for the runway until the last second.
22:58When we put those pieces together, you know, that the pilots did report on the radio,
23:05they had the runway in sight, we had to ask ourselves, did they really?
23:09Did they really see the runway?
23:11Might they have engaged in a little wishful thinking?
23:16This leaves investigators with a troubling question.
23:23They couldn't see the runway.
23:25Why did they go ahead with the landing?
23:26I mean, maybe they were under some kind of pressure.
23:31We needed to know the purpose of this flight, its schedule,
23:35and the pilots' activities before they departed for Aspen.
23:39Looking into what happened before the flight took off from L.A.
23:44can help us gain insight into what might have been going on during the flight.
23:49To understand why the pilots were so intent upon landing in Aspen,
24:03NTSB investigators speak to the Avjet coordinator who managed Flight 303 Gulf Alpha.
24:10The charter coordinators communicated with the pilots moments before the flight departed Los Angeles.
24:17They would have insights into what was concerning the pilots,
24:22what they were trying to accomplish,
24:25and some of the decisions being made.
24:27Did you talk to the captain on the day of the flight?
24:32Oh, yes.
24:33And there were some problems right from the start.
24:35Really?
24:35How so?
24:36Well, the flight was supposed to leave at 4.30.
24:39At 4.15, he called to say the passengers still hadn't shown up.
24:42Well, if the passengers don't show up soon with the long taxi out to the runway,
24:50we won't make it to Aspen in time.
24:52So what are you suggesting?
24:54Well, we may need to divert.
24:58The captain was worried that because of the 7 p.m. noise curfew at Aspen,
25:02he might have to go to Rifle instead, which is about 60 miles away.
25:06So he knew about the noise curfew, and he had a plan to divert if he needed?
25:10Absolutely.
25:12They knew that Rifle Colorado Airport was nearby.
25:17They had planned for alternatives even before they left,
25:19which is exactly what a crew should be doing.
25:23When did the passengers board?
25:26They didn't start boarding until around 4.30.
25:29Then what happened?
25:31About 10 minutes later, I got a phone call from the client's personal assistant,
25:36and he told me the client was very upset.
25:40Hmm.
25:40What's this about diverting to Rifle?
25:43What do you mean?
25:46Once the passengers boarded, there was a call by the charter customer's assistant
25:52expressing concern that the crew had told the passengers that they might have to go to another airport.
26:02Welcome, welcome, given the delay in boarding, looks like we may have to divert to Rifle.
26:07So the client had his assistant call me.
26:15So my boss wants you to tell the pilot to, well, keep his mouth shut around the passengers.
26:23And if he has anything to say, save it until he gets there, and then they can talk it over.
26:29Understood.
26:29There's nothing to worry about.
26:31I'll take care of it.
26:33Thank you very much for letting me know.
26:38So, of course, safety comes first.
26:40But we wanted to keep the client happy.
26:44Did this make it back to the captain?
26:46Yes, I called him right away.
26:49The client's very upset.
26:50He doesn't want you speaking to any of the passengers anymore.
26:53Only to him.
26:54Understood.
26:55Okay.
26:56Don't mention diverting.
26:58Thank you so much.
26:59Yeah.
27:04He was worried that he was going to disappoint our boss, maybe even get into trouble for upsetting the client.
27:11But he wouldn't get into trouble.
27:14In a charter operation, the needs of your passengers are front and center.
27:18You're fully aware of them, and in a situation where a group of people are going to add dinner, and that's the only reason they're taking this trip, if they can't satisfy that timeline, then there was no point of being on that aircraft.
27:34The captain was told not to upset the passengers.
27:38Did that instruction affect his decision about diverting his plane to rifle?
27:43And so this was all before they took off?
27:45Yes.
27:46And was that the last time you spoke to the captain?
27:48No.
27:49He called me again en route to Aspen.
27:52And what time was that?
27:546.30.
27:58We'll be landing in Aspen in about 20, 25 minutes, but we'll have to spend the night there.
28:03No problem.
28:04I can book your rooms.
28:05Hey, how are the passengers?
28:07Are they still upset?
28:10I don't think so.
28:11What about the client?
28:12I had a talk with the client.
28:15It's just really important to him that we make it to Aspen.
28:18Apparently, he's dropping a substantial amount of money on dinner.
28:23The client didn't want to go to Rifle.
28:25Rifle was more than 60 miles away.
28:27It would have taken them too long to get there.
28:29I see.
28:30Okay, well, thank you very much for your time.
28:36Happy to help.
28:37Although the pilots would be aware of the needs of their passengers, at no point can that supersede the professionalism of that crew.
28:49Your primary and only real job is the safety of that aircraft.
28:53You know, it seems they were under a lot of pressure to land, not only before the flight began, but even during the flight.
29:04Crash happened more than half an hour after that last call from the plane.
29:08Did commercial pressure influence the pilots to make a risky decision that cost the lives of 18 people?
29:17You know, this comes up all the time.
29:19Charter pilots often voice on chat rooms and complaint lines that they are pressured to keep people happy and do really difficult things just to satisfy a demanding customer.
29:32And it's dangerous.
29:33NTSB investigators turned to the cockpit voice recorder of Avjet 303 Golf Alpha to understand why the pilots chose to land instead of diverting.
30:00We could learn about the crew's decision-making and what they were doing from their conversations with each other,
30:08you know, how they were planning and using the information that was coming in as they approached Aspen.
30:14You know what, let's pick it up before they begin their final descent.
30:17Hey, do you remember that crazy guy in the Lear when you were in Aspen last time?
30:33It was, I could see the airport.
30:35But he couldn't see it.
30:38How's that?
30:39So, 14 minutes before the crash, they're ridiculing another pilot who tried to land without the runway in sight.
30:51Why did they do the same thing?
30:53At that point, they were still in the mode of, we're going to do this right,
30:58and even sort of made a joke about this one guy that didn't do it right.
31:02Okay.
31:11Okay, we'll shoot her from here.
31:13I mean, we're here, but we only get to do it once.
31:15Right.
31:16Once.
31:17And then we get a rifle, right?
31:19Yeah.
31:20It's too late in the evening to come around.
31:26So, right there, they're talking about doing a missed approach.
31:29That was at 6.50, so two minutes later.
31:35Twelve minutes from the airport, the pilots confirmed their plan to divert if they needed to.
31:42As the crew was approaching Aspen, they were getting the idea that the weather was getting more difficult to get in,
31:48and they were having a conversation about this.
31:51They mentioned again, well, we might only have one shot at this, and we have to go to rifle.
31:55They were really saying the right things.
31:59Attention all aircraft, last aircraft went missed.
32:06What?
32:06You went missed.
32:08You went missed?
32:10Damn.
32:12That's not good.
32:16Nine minutes from crashing.
32:17They know the plane in front of them couldn't land, and they know it's a bad sign for them.
32:26That clearly had to put some pressure on them, say, all right, this is, uh, this is not looking good.
32:33It should have those pilots starting to get into the mindset of executing the missed approach rather than landing the aircraft.
32:39So, they know they shouldn't attempt the landing either.
32:43Up until now, they've been doing everything right by the book.
32:46Yeah.
32:47I wonder what changed.
32:51Investigators discover something unusual in the CVR transcripts.
32:56Huh.
32:56Looks like the flight attendant brought someone into the cockpit.
33:05About eight minutes before the accident, somebody came into the cockpit, one of the passengers.
33:12Thank you very much.
33:13You think it's the client?
33:25It's possible.
33:28Having somebody else up on the flight deck as you're conducting an approach into a mountainous area at night in poor weather is not a good idea.
33:43Did the presence of a passenger in the cockpit play a role in the crash?
33:56Weather's going down.
33:59They're not making it in.
34:01As the crew got closer to Aspen, the weather worsened, making it more dangerous for planes to try to land.
34:09Oh, really?
34:11Oh, really?
34:13The only conversation that should be going on is between the crew about aspects of the flight.
34:20Here, having someone up there questioning their decision-making, questioning, you know, the weather and the operation is just such a distraction and a pressure to them.
34:30As the pilots approached the airport, the situation intensified.
34:36Challenge your 9-8 Romeo, your number one.
34:389-8 Romeo, negative visual on the mist.
34:43They learned that the plane ahead of Avjet 303 Golf Alpha also missed their approach because they couldn't see the runway.
34:51It's too dangerous to land on that runway under these conditions.
34:57So what happened?
35:04Are we cleared to land?
35:06Not yet.
35:08We just missed.
35:09The guy in front of us didn't make it either.
35:11No, really?
35:12Okay, so it sounds like this guy is sending the pilots a message.
35:20Exactly.
35:23O'Reilly may not sound like much, but after all those other things that had occurred, I think O'Reilly was a warning shot.
35:31Get this thing in Aspen.
35:33But the pilots still had one more chance to implement their backup plan to divert to another airport.
35:44Where's it at?
35:48So obviously they still can't see the runway.
35:53To the right.
35:55To the right.
35:55So instead of executing a missed approach, they're still looking for the runway, which is actually to their left.
36:08There was a river valley and some roads nearby.
36:11Might they have seen something they thought was the runway?
36:13You know, some lights of the village or whatnot.
36:16They believed they saw the runway, but that wasn't correct.
36:19They just keep flying lower and lower looking for the airport.
36:22They were just under way too much pressure to make good decisions.
36:31They had the night curfew.
36:33They had the time pressure, pressure from the client as well.
36:37And then with the weather coming in and out, as they stepped down, they'd catch glimpses now and then of the ground.
36:45500.
36:47Rev plus 5.
36:49Think rate.
36:50Think rate.
36:52Think rate.
36:5322 seconds after crossing the missed approach point, Avjet 303 Golf Alpha hits the ground.
37:00Go!
37:02Go!
37:03Go!
37:17Go!
37:17So, in Los Angeles, they were ready to divert.
37:32Then they get chewed out for talking about diverting,
37:35and the client tells them how important the dinner is.
37:38Topping it all off, the passenger enters the cockpit.
37:41So by the time they get to Aspen...
37:43They were bound and determined to land.
37:47Sadly, they turned it to the pilots they were ridiculing.
37:53All indications from our investigation show that these two pilots were good pilots.
38:02Once the crew descended without the runway in sight, the accident was inevitable.
38:11They just kept pushing, and step by step, it got worse and worse until...
38:17They descended too low.
38:20Despite the pressures the pilots were under to land,
38:23there was one more safeguard that could have prevented this tragedy.
38:27You're not going to believe this.
38:28Investigators of Avjet 303 Gulf Alpha examine a safety notice for Aspen Airport that might have prevented the crash.
38:48Anotum.
38:49Notam is an official notice to airmen.
38:55That's a notice put out by the FAA to tell pilots about some abnormality in the airspace system.
39:02An approach procedure has been changed, the navigation aid is out, all sorts of things.
39:07Two days before the crash, a Notam was issued with a warning about landing at Aspen.
39:15As far as I can tell, it says circling NA, not authorized at night.
39:20So, in other words, they should never have been flying into Aspen at night in the first place.
39:26It said that circling, not authorized at night.
39:31This approach is only a circling approach.
39:33Even if you elect to land straight in, it actually had the effect of making that approach not authorized at night.
39:41The crash was at 7.02 p.m. What time was nightfall?
39:46Nightfall was officially at 6.55.
39:51Well, that's seven minutes before the crash. Why didn't they follow the Notam?
39:59Investigators examined the Gulf Stream's briefing records to see if it included the most recent notice.
40:05It looks like the first officer did receive the Notam over the phone before the flight.
40:12So, who knows if he passed it on to the captain.
40:17Notams are hard to read. There's a lot of extraneous information in them.
40:21They tell you about everything from a burned-out light bulb on a tower 15 miles away to the runways closed and everything in between.
40:30And what about the controller?
40:35Notams are also distributed to ATC facilities.
40:39They need to know about things that affect the airspace as well.
40:45It never got passed on to Aspen ATC.
40:54The reason the tower didn't get the Notam is it was supposed to get sent by, believe it or not, fax.
40:59And for whatever reason, it didn't get sent to the ATC facilities that needed to know.
41:06Had the controller received the Notam, it might have prevented the crash.
41:12In the final analysis, investigators conclude the probable cause of the accident was the flight crew's operation of the airplane below the minimum descent altitude without an appropriate visual reference to the runway.
41:25This accident happened because the captain did not go around, did not conduct a missed approach.
41:34Had he done that, they would have gone to rifle, and the passengers may have been frustrated, may have been angry.
41:41There might have been a big conversation, but they would have been alive.
41:44Investigators also believe external pressures played a role in the pilot's decision-making.
41:56We call it get-there-itis.
41:58They were close to the destination, almost there, and the pressure on people to make the decision.
42:04Nothing broke, nothing really failed, other than just the decision-making under pressures of get-there-itis.
42:10As a result of this accident, Avjet restricts flying into Aspen between sunset and sunrise.
42:21The FAA also revises its specifications for flying into Aspen, with a minimum visibility of 5 miles and a cloud ceiling of at least 4,400 feet above ground now required for landing.
42:36You see the runway?
42:37This is to ensure pilots always have a clear view of the runway before landing.
42:45Thank you very much.
42:46Avjet also takes steps to prevent unnecessary distractions in the cockpit during the flight.
42:53After the accident, the company issued a bullet in changing their rules that no passengers were allowed in the cockpit.
43:02Okay, guys, let's finish up tomorrow.
43:05Well, the NTSB has also made a number of recommendations on improving the NOTAM system,
43:13making things a little bit more graphical and easy to use so that people can sort them out, rather than just reading a list.
43:18The lessons serve as a warning to all other pilots who interact with passengers.
43:25I think the message of this flight is there is no dinner, date engagement, or birthday party that is more important than the lives of your passengers on the plane.
43:38And the pilot has to be tough enough to stand up to that, because the passengers just don't know, they're not pilots, and they do not know that their behavior is endangering their very lives.
43:50But it did help change the law, and change how the FAA operates in many aspects, and for that, we're thankful.
43:57And for that, we're thankful.
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