- hace 2 días
El 29 de marzo de 2001, un jet privado chárter y operado por Avjet, descendió por debajo de la altitud mínima de descenso y se estrelló contra la ladera de una montaña durante la aproximación final al Aeropuerto del Condado de Aspen-Pitkin en Colorado, falleciendo las 18 personas a bordo.
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00:00A private charter jet is flying 15 passengers to Aspen, Colorado for a party.
00:06This flight really captured the public attention because of the people on board.
00:12Poor weather makes the landing a challenge for the experienced pilots.
00:17Can you see out there at all yet?
00:19No.
00:20Aspen is considered one of the most dangerous airports in the country.
00:24As the plane nears the runway, the controller watches as disaster unfolds.
00:37Investigators examine the Gulf Stream's wreckage for answers.
00:41I don't see any issues here.
00:44When they learn about the passengers' behavior...
00:48We're running out of fuel here for the birthday boy!
00:51The moving parts of this mystery fall into place.
00:55That clearly had to put some pressure on the pilots to say,
00:57Alright, this is not looking good.
01:01D-D-D-D-D
01:05Pulls up!
01:23The sun has just set over the Colorado mountains.
01:27Avjet November 303 Gulf Alpha is nearing the end of its journey to Aspen.
01:32Well, there's the edge of the night there.
01:37Yeah.
01:39Captain Robert Frisbee has almost 10,000 flying hours to his credit.
01:45What time is official sunset?
01:48He and First Officer Peter Kowalczyk have been flying together for close to five months.
01:55628.
01:58Both pilots have been with Avjet for less than a year.
02:03The small charter airline is based out of Burbank, California.
02:09Avjet catered to high rollers, business people, people who could afford to charter a jet.
02:15People who had to get there in a hurry, but do it in style.
02:20We're running out of fuel here for the birthday boy!
02:25A Miami financier chartered this flight for 14 of his friends to attend a birthday party at an exclusive venue
02:33in Aspen.
02:34This was a group of friends who seemed to have had tremendous early achievements and accomplishments, and they were really
02:42going to go places.
02:46So 4,800 pounds, 126.
02:49It was 50.
02:50You know what? I adjusted it, because the fuel was way off.
02:55The pilots are flying a Gulfstream 3.
03:00The Gulfstream is a luxurious plane that, you know, people see in the movies, and people think high rollers and
03:08movie stars flying.
03:09But it's a workhorse plane. It actually has a good reputation.
03:14It's a 90-minute flight from Los Angeles to Aspen.
03:22Gulfstream 303 Gulf-Alpha, Aspen reduced speed to 210 or slower.
03:28The controller slows down the Gulfstream to maintain a safe distance from the other planes heading into Aspen.
03:37210 or slower, 3 Gulf-Alpha.
03:4417 minutes from landing, the pilots begin their descent.
03:50Aspen-Pitkin County Airport, also known as Sardi Field, is about 3 miles northwest of Aspen.
03:57Landing on its single runway is a challenge.
04:02Aspen is considered one of the most dangerous airports in the country.
04:07The runway is not long, and it is in close proximity to high terrain on all sides.
04:17Hey, do you remember that crazy guy in the Lear when we were in Aspen last time?
04:23It was, I can see the airport, but he couldn't see it.
04:29Set you up on the approach.
04:31The landing is made even more difficult, with the final stage needing to be carried out visually.
04:39As the plane nears Aspen, a beacon guides it to the airport.
04:43But 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.
04:53Because of the high terrain and close proximity to the final approach course,
04:57the 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.
05:14And if at any time it's snowing, it's very hard to acquire that visual reference
05:21to safely descend further to a landing.
05:27Residential noise restrictions around the airport leave the pilots only nine minutes
05:32until the landing curfew at 6.58.
05:34The crew is cutting it close.
05:39Can you see out there at all yet?
05:43Uh...
05:44No.
05:48Kofstream 3 Golf Alpha, heading 050.
05:52Heading 050, 3 Golf Alpha.
05:57As the pilots prepare to line up with the runway, passengers get ready for landing.
06:11Synchronizer's off.
06:13There is just enough fuel for one landing attempt.
06:16After that, the pilots will have to divert to another airport.
06:20Okay, it's off.
06:24Hydraulic pressure's good.
06:27Gulfstream 3 Golf Alpha, turn heading 1-4-0.
06:31Intercept 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.
06:43Intercept final approach course, 3 Golf Alpha.
06:491-6-thousand.
06:55As the pilots get their final intercept to the airport...
07:01Challenger 7 Juliet Alpha, you have the airport in sight.
07:05Another aircraft, also on approach to Aspen, updates the controller.
07:10Uh, that's a negative. Going around.
07:14Those pilots aboard their landing, because they can't see the runway.
07:21Attention all aircraft, last aircraft went missed.
07:25What?
07:26You went missed.
07:28You went missed?
07:29Damn.
07:31That's not good.
07:34If you can't successfully land the aircraft, then a missed approach is a procedure that pilots will execute to return
07:41to a safe altitude.
07:44As the Gulf Stream gets closer to the airport, the weather deteriorates.
08:09The 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.
08:21Otherwise, you're expected to execute a missed approach.
08:26Red table at 1-4-thousand, cleared for VOR approach.
08:29Gulf Stream 303, Gulf Alpha.
08:33Here we go.
08:37As the pilots get closer to the airport, they're counting on the weather to improve for their landing.
08:44Sending to 1-4-thousand.
08:47Problems 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.
09:01Landing flaps.
09:03Just 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.
09:13Can you see the runway?
09:16Can you see the runway?
09:20Gulf Stream 3, Gulf Alpha, you have the runway in sight?
09:27Affirmative.
09:27Yeah, now we do.
09:28Runway in sight, 3 Gulf Alpha.
09:31Gulf Stream 3, Gulf Alpha, visual.
09:33Roger.
09:351,000?
09:361,000 to go.
09:39The pilots are now less than a minute from landing.
09:52At the last moment, they realize something is wrong.
10:14Avjet 303 Gulf Alpha crashes just short of the runway at Aspen.
10:21Aircraft identification Gulf Stream 303 Gulf Alpha.
10:25Aircraft identification Gulf Stream 303 Gulf Alpha.
10:26The first location, it was north of the runway, approximately the Shale Bluffs area.
10:33Emergency vehicles rush to the scene in the hope that there are survivors of the crash of Avjet 303 Gulf
10:40Alpha.
10:49But all 18 people on board are dead.
10:53All 15 passengers, the two pilots, and the flight attendant.
11:05This flight really captured the media and the public attention because of the people on board.
11:12There were a lot of very young, talented people.
11:21Put everything from the tail section over there.
11:26By the following day, investigators are on site.
11:32Thousands of passengers fly charter airplanes every year, encompassing 2.5 million flight hours annually.
11:41So trying to understand why this accident occurred was significant.
11:50Let me see that.
11:52Within hours, the plane's cockpit voice recorder, or CVR, is retrieved from the wreckage.
11:59Let's get the data pulled from that ASAP.
12:02What about a flight data recorder?
12:09Looks like there wasn't one.
12:12Okay.
12:15Because the airplane was manufactured in 1980 and registered in 1981, it was not required to have an FDR.
12:24While the CVR is sent for analysis, investigators from the National Transportation Safety Board wonder why the pilots weren't able
12:32to land safely.
12:33The plane crashed 2,400 feet from the runway.
12:39When an aircraft crashes short of a runway, especially a sophisticated airplane like a Gulfstream jet, a number of questions
12:45arise here.
12:46How did they get there?
12:47What possible factors could the crew have?
12:49Was there some sort of a failure in the aircraft?
12:54Take a look at this.
12:57What do you think caused that?
12:59There's a deep ground scar at the crash site.
13:05That would do it.
13:07Investigators 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.
13:20And we can look at those branches and the angles that are made to understand the airplane's attitude as it
13:27came into the ground and its descent profile.
13:32Left wing struck the trees at about 49 degrees.
13:41That's a hell of a bank.
13:48There is no operationally relevant reason for an airplane to be banked at 49 degrees that close to the airport
13:55or that close to the ground.
13:58Maybe they lost control of the plane.
14:02When we see an aircraft in an abnormal attitude, we've got to look at, did something happen where the pilots
14:08couldn't keep it level?
14:09The plane's position gives investigators a promising lead.
14:15Engine failure?
14:18The loss of thrust resulting from an engine failure on one side can yaw the airplane, and if not appropriately
14:25managed by the pilots in a timely fashion, can lead to a loss of control.
14:33Aside 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.
14:47When the Gulfstream 3's engines are working, the compressor blades spin in a clockwise direction.
14:53If the engines were still functioning when the plane crashed, these blades would be bent counter-clockwise or in the
15:00opposite direction.
15:06You know, these are all bent counter-clockwise, so it wasn't engine failure.
15:12Our examination of the engines showed that there was no pre-existing damage, no evidence of an in-flight fire,
15:20and also showed that they were operating normally and at high power at the time of the impact.
15:26Let'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,
15:38or also stall one of the wings, which would further exacerbate the rolling moment.
15:46Investigators examine the actuator that controls the rudder's movement.
15:51The piston is completely intact.
15:55No sign of any damage.
15:59There was no pre-existing conditions or failures that would have explained the accident.
16:06The airplane was functioning normally.
16:08If 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.
16:20What was it doing? Where was it flying? How fast was it going?
16:27Have a look at this radar data.
16:31With no flight data recorder, investigators turn to Aspen's radar information to reconstruct the Gulf Stream's descent profile.
16:42Using the radar position and time, so the altitude and position of the aircraft,
16:47the performance engineers can extract the speed of the aircraft.
16:51How fast is it descending?
16:53Is that appropriate for the approach that they're trying to do?
16:58Here's what we've got.
17:02This is the approach they should have flown.
17:05Investigators examine the path the pilots were required to follow into Aspen.
17:12Due to the rising terrain away from the airport, Aspen at this time had a step-down approach, which, from
17:19a profile, looks like stairs.
17:22The pilots will step down to an altitude based on the terrain availability.
17:28Pilots cannot descend below that altitude until they reach another fix or another distance.
17:38And here's the descent the pilots actually flew.
17:42The radar data shows the Avjet flight deviated from the published descent profile.
17:50Four miles out, they dropped 300 feet below the minimum.
17:53And a mile later, they dropped 900 feet below the minimum altitude.
17:58And they stayed that way.
18:00They flew in very low.
18:05If you go below a minimum altitude before you are allowed to, then you no longer can guarantee the safety
18:12of that aircraft.
18:20Why would they do that?
18:23Because the pilots did not fly this approach to standards, we wanted to look into their backgrounds and training to
18:31better understand why the accident may have occurred.
18:38Why did the pilots of Avjet 303 Golf Alpha not follow the prescribed approach procedure into Aspen?
18:48The captain passed his last proficiency check.
18:51So did the first officer just a couple months ago.
18:56Investigators learn that all Avjet pilots are trained to land in mountainous terrain like Aspen.
19:03And they both flew into Aspen together twice before, without incident.
19:09No accidents.
19:11No reprimands.
19:14Even 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.
19:23They were both well-qualified, well-trained, and experienced to fly this airplane and make this trip.
19:29And they both got plenty of sleep before the flight, so fatigue isn't an issue.
19:34In fact, I don't see any issues here.
19:39This doesn't make any sense.
19:44Why would two well-trained pilots fly so recklessly below the limits?
19:51No matter whether you're a charter pilot or an airline pilot or even just a personal general aviation pilot, you
19:57know, our number one job is safety.
19:59Regulations are there for a reason.
20:01What 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.
20:15What was different this time?
20:19Maybe they were trying to get eyes on the runway?
20:22Pull up the weather.
20:33It was important to understand exactly what was going on with the weather in terms of the layers of clouds,
20:40whether they were solid or broken, to understand what capability these pilots may have had to see objects on the
20:49ground.
20:51The crash was at 7.02 PM. Back it up to about 6.30 PM.
20:58They would have been flying in and out of some pretty heavy cloud here.
21:02So, maybe they didn't have a clear line on the runway.
21:05Okay, but these are seasoned pilots. They should know if you don't see the runway...
21:09You don't try to land on it.
21:10And yet they did try to land on it.
21:12And they missed by almost half a mile. So, did they see the runway or not?
21:19We should talk to the controller.
21:24An air traffic controller can tell you what the visibility is, what the weather conditions were, what other airplanes were
21:32doing in terms of coming into the airport.
21:35And provide eyewitness testimony about the time of the accident, but they also can help us understand communications that they
21:43had with the airplane.
21:47So, did they give you any indication at all that they were having trouble seeing the runway?
21:52No. Quite the opposite. I asked them if they could see the runway, and they confirmed that they did.
21:58Gulfstream 3 Gulf Alpha, you have the runway in sight?
22:01Yeah, runway in sight, 3 Gulf Alpha.
22:05Gulfstream 3 Gulf Alpha, visual. Roger.
22:09Hmm.
22:11I made extra sure to confirm. Because I couldn't see them. The weather was so bad.
22:18Did you have any reason to doubt the pilots?
22:22Not at the time.
22:24But...
22:25Here's what's so odd.
22:27They confirmed they had visual, but then when they came out of the clouds, they were headed to the right
22:32of the airport.
22:43What are they doing?
22:49What are they doing?
22:52I don't think they realized they weren't headed for the runway until the last second.
22:59When we put those pieces together, you know, that the pilots did report on the radio, they had the runway
23:04in sight.
23:04We had to ask ourselves, did they really? Did they really see the runway?
23:08Um, might they have engaged in a little wishful thinking?
23:14This leaves investigators with a troubling question.
23:20They couldn't see the runway. Why did they go ahead with the landing?
23:25Maybe they were under some kind of pressure.
23:29We needed to know the purpose of this flight, its schedule, and the pilots' activities before they departed for Aspen.
23:37Looking into what happened before the flight took off from L.A.
23:42can help us gain insight into what might have been going on during the flight.
23:51So sorry to keep you waiting.
23:53No problem at all.
23:55To understand why the pilots were so intent upon landing in Aspen,
24:00NTSB investigators speak to the Avjet coordinator who managed Flight 303 Gulf Alpha.
24:07The charter coordinators communicated with the pilots moments before the flight departed Los Angeles.
24:15They would have insights into what was concerning the pilots, what they were trying to accomplish, and some of the
24:24decisions being made.
24:26Did you talk to the captain on the day of the flight?
24:29Oh, yes. And there were some problems right from the start.
24:32Really? How so?
24:34Well, the flight was supposed to leave at 4.30.
24:36At 4.15, he called to say the passengers still hadn't shown up.
24:43If the passengers don't show up soon with the long taxi out to the runway, we won't make it to
24:48Aspen in time.
24:49So what are you suggesting?
24:51Well, we may need to divert.
24:55The captain was worried that because of the 7 p.m. noise curfew at Aspen, he might have to go
25:01to Rifle instead, which is about 60 miles away.
25:04So he knew about the noise curfew, and he had a plan to divert if he needed?
25:08Absolutely.
25:11They knew that Rifle Colorado Airport was nearby.
25:14They had planned for alternatives even before they left, which is exactly what a crew should be doing.
25:21When did the passengers board?
25:23They didn't start boarding until around 4.30.
25:27Then what happened?
25:29About 10 minutes later, I got a phone call from the client's personal assistant, and he told me the client
25:34was very upset.
25:39What's this about diverting to Rifle?
25:41What do you mean?
25:43Once the passengers boarded, there was a call by the charter customer's assistant expressing concern that the crew had told
25:56the passengers that they might have to go to another airport.
26:00Welcome. Welcome. Given the delay in boarding, looks like we may have to divert to Rifle.
26:10So the client had his assistant call me.
26:14So my boss wants you to tell the pilot to, well, keep his mouth shut around the passengers.
26:20And if he has anything to say, save it until he gets there, and then they can talk it over.
26:26Understood. There's nothing to worry about. I'll take care of it.
26:30Thank you very much for letting me know.
26:35So, of course, safety comes first. But we wanted to keep the client happy.
26:41Did this make it back to the captain?
26:43Yes, I called him right away.
26:46The client's very upset. He doesn't want you speaking to any of the passengers anymore. Only to him.
26:52Understood. Okay. Don't mention diverting.
26:55Thank you so much.
26:57Yeah.
27:01He was worried that he was going to disappoint our boss, maybe even get into trouble for upsetting the client,
27:08but he wouldn't get into trouble.
27:11In a charter operation, the needs of your passengers are front and center.
27:16You're fully aware of them.
27:17And in a situation where a group of people are going to add dinner, and that's the only reason they're
27:24taking this trip.
27:25If they can't satisfy that timeline, then there was no point of being on that aircraft.
27:31The captain was told not to upset the passengers. Did that instruction affect his decision about diverting his plane to
27:39rifle?
27:40And so this was all before they took off?
27:43Yes.
27:44And was that the last time you spoke to the captain?
27:46No. He called me again en route to Aspen.
27:49And what time was that?
27:526.30.
27:55We'll be landing in Aspen in about 20-25 minutes, but we'll have to spend the night there.
28:01No problem, Mike and Bookie rooms.
28:03Hey, how are the passengers? Are they still upset?
28:07I don't think so.
28:08What about the client?
28:11I had a talk with the client. It's just really important to him that we make it to Aspen.
28:15And apparently he's dropping a substantial amount of money on dinner.
28:20The client didn't want to go to Rifle.
28:22Rifle was more than 60 miles away. It would have taken them too long to get there.
28:26I see.
28:29Okay. Wow.
28:32Thank you very much for your time.
28:34Happy to help.
28:37Although the pilots would be aware of the needs of their passengers,
28:41at no point can that supersede the professionalism of that crew.
28:47Your primary and only real job is the safety of that aircraft.
28:52You know, it seems they were under a lot of pressure to land,
28:56not only before the flight began, but even during the flight.
29:02Crash happened more than half an hour after that last call from the plane.
29:07Did commercial pressure influence the pilots to make a risky decision that cost the lives of 18 people?
29:15You know, this comes up all the time.
29:17Charter pilots often voice on chat rooms and complaint lines
29:22that they are pressured to keep people happy and do really difficult things
29:27just to satisfy a demanding customer. And it's dangerous.
29:33They still had time to correct the situation. So what happened in these final 30 minutes?
29:44It's here.
29:47NTSB investigators turned to the cockpit voice recorder of Avjet 303 Golf Alpha
29:53to understand why the pilots chose to land instead of diverting.
29:59We could learn about the crew's decision making and what they were doing
30:02from their conversations with each other.
30:04I mean, how they were planning and using the information that was coming in
30:09as they approached Aspen.
30:11You know what, let's pick it up before they begin their final descent.
30:25Hey, do you remember that crazy guy in the Lear when you were in Aspen last time?
30:30It was, I could see the airport.
30:32But he couldn't see it.
30:35How was that?
30:40So, 14 minutes before the crash, they're ridiculing another pilot who tried to land without the runway in sight.
30:47Why did they do the same thing?
30:50At that point, they were still in the mode of, we're going to do this right,
30:55and even sort of made a joke about this one guy that didn't do it right.
31:04Okay.
31:08Okay.
31:08Okay, we'll shoot it from here.
31:10I mean, we're here, but we only get to do it once.
31:13Right, once.
31:14And then we get a rifle, right?
31:16Yeah, it's too late in the evening to come around.
31:23So, right there, they're talking about doing a missed approach.
31:27That was at 6.50, so two minutes later.
31:3212 minutes from the airport, the pilots confirmed their plan to divert if they needed to.
31:39As the crew was approaching Aspen, they were getting the idea that the weather was getting more difficult to get
31:45in,
31:45and they were having a conversation about this.
31:47They mentioned again, well, we might only have one shot at this, and we have to go to rifle.
31:52They were really saying the right things.
32:02What?
32:03You went missed.
32:05You went missed?
32:06Damn.
32:08That's not good.
32:12Nine minutes from crashing.
32:16They know the plane in front of them couldn't land, and they know it's a bad sign for them.
32:23That clearly had to put some pressure on them, say, all right, this is not looking good.
32:29It should have those pilots starting to get into the mindset of executing the missed approach rather than landing the
32:36aircraft.
32:37So they know they shouldn't attempt the landing either.
32:40Up until now, they've been doing everything right by the book.
32:43Yeah.
32:44I wonder what changed.
32:48Investigators discover something unusual in the CVR transcripts.
32:53Huh.
32:56Looks like the flight attendant brought someone into the cockpit.
33:02About eight minutes before the accident, somebody came into the cockpit, one of the passengers.
33:08Thank you very much.
33:17You think it's the client?
33:22It's possible.
33:25Having somebody else up on the flight deck as you're conducting an approach into a mountainous area at night in
33:34poor weather is not a good idea.
33:40Did the presence of a passenger in the cockpit play a role in the crash?
33:53Weather's gone down.
33:56They're not making it in.
33:58As the crew got closer to Aspen, the weather worsened, making it more dangerous for planes to try to land.
34:06Oh, really?
34:08Oh, really?
34:12The only conversation that should be going on is between the crew about aspects of the flight.
34:17Here, having someone up there questioning their decision-making, questioning, you know, the weather and the operation is just such
34:24a distraction and a pressure to them.
34:27As the pilots approached the airport, the situation intensified.
34:33Challenge your 9-8 Romeo, your number one.
34:369-8 Romeo, negative visual on the mist.
34:40They learned that the plane ahead of Avjet 303 Golf Alpha also missed their approach because they couldn't see the
34:48runway.
34:49It's too dangerous to land on that runway under these conditions.
34:53So what happened?
35:01Are we cleared to land?
35:03Not yet.
35:04We just missed. The guy in front of us didn't make it either.
35:08No, really?
35:13Okay, so it sounds like this guy is sending the pilots a message.
35:17Exactly.
35:20O'Reilly may not sound like much, but after all those other things that had occurred, I think O'Reilly
35:26was a warning shot.
35:28Get this thing in Aspen.
35:31But the pilots still had one more chance to implement their backup plan to divert to another airport.
35:41Where's it at?
35:44So obviously they still can't see the runway.
35:50To the right. To the right.
35:58So instead of executing a missed approach, they're still looking for the runway, which is actually to their left.
36:05There was a river valley and some roads nearby.
36:08Might they have seen something they thought was the runway?
36:10You know, some lights of the village or whatnot.
36:12They believed they saw the runway, but that wasn't correct.
36:16They just keep flying lower and lower, looking for the airport.
36:21They were just under way too much pressure to make good decisions.
36:28They had the night curfew.
36:30They had the time pressure, pressure from the client as well.
36:33And then with the weather coming in and out, as they step down, they'd catch glimpses now and then of
36:40the ground.
36:42500.
36:44Rev plus 5.
36:46Think rate. Think rate.
36:5022 seconds after crossing the missed approach point, Avjet 303 Golf Alpha hits the ground.
36:58No!
37:10No!
37:13No!
37:13No!
37:13No!
37:14No!
37:22No!
37:22So, in Los Angeles, they were ready to divert.
37:29Then they get chewed out for talking about diverting, and the client tells them how important the dinner is.
37:35Topping it all off, the passenger enters the cockpit.
37:38So by the time they get to Aspen...
37:40They were bound and determined to land.
37:45Sadly, they turned into the pilots they were ridiculing.
37:50All indications from our investigation show that these two pilots were good pilots.
37:59Once the crew descended without the runway in sight, the accident was inevitable.
38:08They just kept pushing, and step by step, it got worse and worse until they descended too low.
38:16Despite the pressures the pilots were under to land, there was one more safeguard that could have prevented this tragedy.
38:24You're not gonna believe this.
38:35Investigators of Avjet 303 Golf Alpha examine a safety notice for Aspen Airport that might have prevented the crash.
38:45A NOTAM.
38:47A NOTAM.
38:48NOTAM is an official notice to airmen.
38:52That's a notice put out by the FAA to tell pilots about some abnormality in the airspace system.
38:58An approach procedure has been changed, a navigation aid is out, all sorts of things.
39:05Two days before the crash, a NOTAM was issued with a warning about landing at Aspen.
39:12As far as I can tell, it says circling NA not authorized at night.
39:17So in other words, they should never have been flying into Aspen at night in the first place.
39:22It said that circling not authorized at night.
39:27This approach is only a circling approach, even if you elect to land straight in.
39:32It actually had the effect of making that approach not authorized at night.
39:39The crash was at 7.02 PM. What time was nightfall?
39:42Nightfall was officially at 6.55.
39:48Well, that's seven minutes before the crash. Why didn't they follow the NOTAM?
39:55Investigators examined the Gulf Stream's briefing records to see if it included the most recent notice.
40:03It looks like the first officer did receive the NOTAM over the phone before the flight.
40:08So who knows if he passed it on to the captain?
40:13NOTAMs are hard to read. There's a lot of extraneous information in them.
40:17They tell you about everything from a burned out light bulb on a tower 15 miles away to the runways
40:23closed and everything in between.
40:26And what about the controller?
40:32NOTAMs are also distributed to ATC facilities.
40:35They need to know about things that affect the airspace as well.
40:41It never got passed on to Aspen ATC.
40:50The reason the tower didn't get the NOTAM is it was supposed to get sent by, believe it or not,
40:55fax.
40:56And for whatever reason, didn't get sent to the ATC facilities that needed to know.
41:02Had the controller received the NOTAM, it might have prevented the crash.
41:08In the final analysis, investigators conclude the probable cause of the accident
41:13was the flight crew's operation of the airplane below the minimum descent altitude
41:18without an appropriate visual reference to the runway.
41:23This accident happened because the captain did not go around, did not conduct a missed approach.
41:30Had he done that, they would have gone to rifle.
41:34And the passengers may have been frustrated, may have been angry.
41:38There might have been a big conversation, but they would have been alive.
41:45Investigators also believe external pressures played a role in the pilot's decision-making.
41:52We call it get-there-itis.
41:54They were close to the destination, almost there, and the pressure on people to make the decision.
42:00Nothing 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.
42:17The FAA also revises its specifications for flying into Aspen,
42:21with a minimum visibility of 5 miles,
42:24and a cloud ceiling of at least 4,400 feet above ground now required for landing.
42:33Can you see the runway?
42:35This is to ensure pilots always have a clear view of the runway before landing.
42:41Thank you very much.
42:43Avjet also takes steps to prevent unnecessary distractions in the cockpit during the flight.
42:49After the accident, the company issued a bullet in changing their rules that no passengers were allowed in the cockpit.
42:59OK, guys, let's finish up tomorrow.
43:03Well, the NTSB has also made a number of recommendations on improving the NOTAM system,
43:09making things a little bit more graphical and easy to use so that people can sort them out, rather than
43:14just reading a list.
43:16The lessons serve as a warning to all other pilots who interact with passengers.
43:23I think the message of this flight is there is no dinner, date engagement, or birthday party that is more
43:31important than the lives of your passengers on the plane.
43:35And the pilot has to be tough enough to stand up to that, because the passengers just don't know.
43:42They're not pilots, and they do not know that their behavior is endangering their very lives.
43:48But it did help change the law and change how the FAA operates in many aspects, and for that we're
43:55thankful.