- hace 15 horas
On 29 March 2001, a chartered business jet operated by Avjet crashes into a hillside while on final approach to Aspen/Pitkin County Airport in Colorado, killing all 18 people on board. The cause of the accident was the pilots' premature descent below the minimum descent altitude.
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00:00A 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.
00:17Can 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.
00:32What are they doing?
00:37Investigators examine the Gulf Stream's wreckage for answers.
00:42I 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!
00:52The 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-D
01:06Oh, fuck!
01:24The sun has just set over the Colorado mountains.
01:28Avjet November 303 Gulf Alpha is nearing the end of its journey to Aspen.
01:33Well, there's the edge of the night there.
01:38Yeah.
01:40Captain Robert Frisbee has almost 10,000 flying hours to his credit.
01:46What time is official sunset?
01:49He and First Officer Peter Kowalczyk have been flying together for close to five months.
01:56628.
01:59Both pilots have been with Avjet for less than a year.
02:04The small charter airline is based out of Burbank, California.
02:10Avjet 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.
02:20We'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.
02:35This was a group of friends who seemed to have had tremendous early achievements and accomplishments, and they were really
02:43going to go places.
02:46So 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 Gulfstream 3.
03:01The Gulfstream is a luxurious plane that, you know, people see in the movies, and people think high rollers and
03:08movie stars flying.
03:10But it's a workhorse plane. It actually has a good reputation.
03:15It's a 90-minute flight from Los Angeles to Aspen.
03:22Gulfstream 303 Gulf Alpha, Aspen reduced speed to 210 or slower.
03:29The 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.
03:58Landing 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.
04:18Hey, 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.
04:30Set you up on the approach.
04:31Okay.
04:33The 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.
04:44But it doesn't lead it directly to the runway.
04:48Once 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, the minimum altitude is a couple thousand
05:01feet above the ground.
05:02And we must be visual by that time to safely continue our descent down to a landing.
05:09And tonight, the weather isn't making landing any easier.
05:15And if at any time it's snowing, it's very hard to acquire that visual reference to safely descend further to
05:24a landing.
05:28Residential 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?
05:44Uh...
05:45No.
05:49Gulfstream 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.
06:11Okay, synchronizer's off.
06:14There is just enough fuel for one landing attempt.
06:17After that, the pilots will have to divert to another airport.
06:21Okay, it's off.
06:24Hydraulic pressure's good.
06:27Gulfstream 3 Gulf Alpha, turn heading 140, intercept final approach course, maintain 16000.
06:35Eight minutes from the airport, the controller gives the crew clearance to commence the approach.
06:42140, 16000, intercept final approach course 3 Gulf Alpha.
06:5016000.
06:56As the pilots get their final intercept to the airport.
07:02Challenger 7, Juliet Alpha, you have the airport in sight.
07:05Another aircraft, also on approach to Aspen, updates the controller.
07:11Uh, 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.
07:26What?
07:27Wet missed.
07:28Wet missed?
07:30Damn.
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 to return
07:42to a safe altitude.
07:45As the Gulfstream gets closer to the airport, the weather deteriorates.
07:59Gulfstream 3 Gulf Alpha, five miles from Red Table, cross Red Table at or above 14000, clear VOR DME Charlie
08:07approach.
08:09The controller clears the pilots to begin the final approach, 11 miles from the airport.
08:18You 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 14000, cleared for VOR approach, Gulfstream 303 Gulf Alpha.
08:34Here we go.
08:37As the pilots get closer to the airport, they're counting on the weather to improve for their landing.
08:45Resetting to 14000.
08:48Problems can escalate very quickly when flying into Aspen.
08:52There's really no room to recover without breaking off that approach or trying it again.
09:00Landing flaps.
09:02Landing flaps.
09:03Just over two minutes from landing, instruments have successfully guided the pilots to the airport.
09:10Now it's up to them to identify the runway.
09:14You see the runway?
09:21Gulfstream 3 Gulf Alpha, you have the runway in sight?
09:27Affirmative.
09:28Yeah, now we do.
09:29Runway in sight, 3 Gulf Alpha.
09:32Gulfstream 3 Gulf Alpha, visual.
09:34Roger.
09:351,000.
09:371,000.
09:381,000 to go.
09:391,000 to go.
09:40The pilots are now less than a minute from landing.
09:52200.
09:53At the last moment, they realize something is wrong.
09:58Go!
09:59Go!
10:00Go!
10:00Go!
10:01Go!
10:01Go!
10:02Go!
10:04Go!
10:06Go!
10:06Go!
10:10Go!
10:11Go!
10:15Avjet 303 Gulf Alpha crashes just short of the runway at Aspen.
10:22Aircraft identification, Gulfstream 303 Gulf Alpha.
10:26Aircraft location, it was north of the runway, approximately the Shale Bluffs area.
10:34Emergency vehicles rush to the scene in the hope that there are survivors of the crash of Avjet 303 Gulf
10:41Alpha.
10:50But all 18 people on board are dead.
10:54All 15 passengers, the two pilots, and the flight attendant.
11:06This 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.
11:22Put 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.
11:51Let me see that.
11:53Within hours, the plane's cockpit voice recorder, or CVR, is retrieved from the wreckage.
12:00Let's get the data pulled from that ASAP.
12:03What about a flight data recorder?
12:10Looks like there wasn't one.
12:13Okay.
12:16Because 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
12:34to land safely.
12:35The plane crashed 2,400 feet from the runway.
12:40When an aircraft crashes short of runway, especially a sophisticated airplane like a Gulfstream jet, a number of questions arise
12:47here.
12:47How did they get there?
12:48What possible factors could the crew have?
12:50Was there some sort of a failure in the aircraft?
12:56Take a look at this.
12:58What do you think caused that?
13:00There's a deep ground scar at the crash site.
13:06That would do it.
13:08Investigators conclude that it was formed when the left wing hit the ground.
13:14When an airplane comes through trees or vegetation as it approaches the ground, it cuts off branches.
13:21And we can look at those branches and the angles that are made to understand the airplane's attitude as it
13:29came 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.
13:49There is no operationally relevant reason for an airplane to be banked at 49 degrees that close to the airport
13:56or that close to the ground.
13:59Maybe they lost control of the plane.
14:03When we see an aircraft in an abnormal attitude, we've got to look at did something happen where, you know,
14:09the pilots couldn't keep it level.
14:11The plane's position gives investigators a promising lead.
14:16Engine failure?
14:19The loss of thrust resulting from an engine failure on one side can yaw the airplane, and if not appropriately
14:27managed 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.
14:39The 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
15:02direction.
15:02You know, these are all bent counterclockwise, so it wasn't engine failure.
15:13Our examination of the engines showed that there was no pre-existing damage, no evidence of an in-flight fire,
15:21and 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.
15:30An airplane operating at a low airspeed while the rudder moves to an extreme limit could introduce a rolling moment
15:39or also stall one of the wings, which would further exacerbate the rolling moment.
15:47Investigators examine the actuator that controls the rudder's movement.
15:52The piston is completely intact.
15:56No sign of any damage.
16:00There 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?
16:16Determining the airplane's flight path helps us understand how that airplane got to the accident site.
16:21What was it doing? Where was it flying? How fast was it going?
16:28Have a look at this radar data.
16:32With no flight data recorder, investigators turn to Aspen's radar information to reconstruct the Gulf Stream's descent profile.
16:43Using the radar position and time, so the altitude and position of the aircraft, the performance engineers can extract the
16:51speed of the aircraft.
16:52How fast is it descending? Is that appropriate for the approach that they're trying to do?
17:00Here's what we've got.
17:03Here's what we've got.
17:04This is the approach they should have flown.
17:07Investigators examine the path the pilots were required to follow into Aspen.
17:13Due to the rising terrain away from the airport, Aspen at this time had a step-down approach, which from
17:20a profile looks like stairs.
17:23The 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.
17:40And here's the descent the pilots actually flew.
17:43The 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.
17:59And 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
18:14of that aircraft.
18:21Why 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
18:32better understand why the accident may have occurred.
18:40Why 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.
19:05And 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.
19:20So looking into the background of this flight crew, we really didn't see anything that stood out.
19:24They 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.
19:40This doesn't make any sense.
19:46Why would two well-trained pilots fly so recklessly below the limits?
19:53No matter whether you're a charter pilot, or an airline pilot, or even just a personal general aviation pilot,
19:59our number one job is safety. Regulations are there for a reason.
20:03What is it that could lead a good flight crew to go beyond those safety limits?
20:11Okay, 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?
20:24Pull up the weather.
20:35It was important to understand exactly what was going on with the weather in terms of the layers of clouds,
20:42whether 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 PM.
20:55That got up to about 6.30 PM.
21:00They would have been flying in and out of some pretty heavy cloud here.
21:04So, maybe they didn't have a clear line on the runway.
21:07Okay, but these are seasoned pilots. They should know if you don't see the runway...
21:11You don't try to land on it.
21:12And 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.
21:26An air traffic controller can tell you what the visibility is, what the weather conditions were,
21:32what 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.
21:49So, 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?
22:03Yeah, runway in sight, 3 Gulf Alpha.
22:07Gulfstream 3 Gulf Alpha, visual. Roger.
22:13I made extra sure to confirm. Because I couldn't see them. The weather was so bad.
22:20Did you have any reason to doubt the pilots?
22:23Not at the time. But here's what's so odd.
22:29They confirmed they had visual, but then when they came out of the clouds,
22:32they were headed to the right of the airport.
22:45What are they doing?
22:54I don't think they realized they weren't headed for the runway until the last second.
23:01When we put those pieces together, you know, that the pilots did report on the radio, they had the runway
23:06in sight.
23:06We had to ask ourselves, did they really? Did they really see the runway?
23:10Um, might they have engaged in a little wishful thinking?
23:16This leaves investigators with a troubling question.
23:22They couldn't see the runway. Why did they go ahead with the landing?
23:27Maybe they were under some kind of pressure.
23:31We needed to know the purpose of this flight, its schedule, and the pilots' activities before they departed for Aspen.
23:39Looking into what happened before the flight took off from LA can help us gain insight into what might have
23:47been going on during the flight.
23:54So sorry to keep you waiting.
23:56No problem at all.
23:58To 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, what they were trying to accomplish, and some of the
24:26decisions being made.
24:28Did you talk to the captain on the day of the flight?
24:31Oh, yes. And there were some problems right from the start.
24:34Really? How so?
24:36Well, the flight was supposed to leave at 4.30. At 4.15, he called to say the passengers still
24:41hadn't shown up.
24:45Well, if the passengers don't show up soon with the long taxi out to the runway, we won't make it
24:51to 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, he might have to go
25:03to 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.
25:13They knew that Rifle Colorado Airport was nearby. They had planned for alternatives even before they left, which is exactly
25:20what a crew should be doing.
25:23When did the passengers board?
25:25They 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 and he told me the client
25:37was very upset.
25:41What'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 expressing concern that the crew had told
25:59the 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 the rifle.
26:12So the client had his assistant call me.
26:16So 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. There's nothing to worry about. I'll take care of it.
26:32Thank you very much for letting me know.
26:37So, of course, safety comes first. But we wanted to keep the client happy.
26:43Did this make it back to the captain?
26:45Yes, I called him right away.
26:49The client's very upset. He doesn't want you speaking to any of the passengers anymore. Only to him.
26:54Understood. Okay. Don't mention diverting.
26:57Thank 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. You're fully aware of them.
27:19And in a situation where a group of people are going to add dinner and that's the only reason they're
27:26taking this trip.
27:27If they can't satisfy that timeline, then there was no point of being on that aircraft.
27:33The captain was told not to upset the passengers. Did that instruction affect his decision about diverting his plane to
27:42rifle?
27:42And so this was all before they took off?
27:45Yes.
27:46And was that the last time you spoke to the captain?
27:48No. He called me again en route to Aspen.
27:51And what time was that?
27:546.30.
27:57We'll be landing in Aspen in about 20, 25 minutes, but we'll have to spend the night there.
28:03No problem. I can book your rooms.
28:05Hey, how are the passengers? Are they still upset?
28:09I don't think so.
28:11What about the client?
28:13I had a talk with the client. It's just really important to him that we make it to Aspen.
28:17Apparently, he's dropping a substantial amount of money on dinner.
28:22The client didn't want to go to Rifle. Rifle was more than 60 miles away. It would have taken them
28:27too long to get there.
28:29I see.
28:32Okay. Wow.
28:34Thank you very much for your time.
28:36Happy to help.
28:39Although the pilots would be aware of the needs of their passengers,
28:44at no point can that supersede the professionalism of that crew.
28:49Your primary and only real job is the safety of that aircraft.
28:55You know, it seems they were under a lot of pressure to land,
28:59not 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.
29:09Did 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
29:28and do really difficult things just to satisfy a demanding customer.
29:32And it's dangerous.
29:35They still had time to correct the situation, so what happened in these final 30 minutes?
29:47It's here.
29:50NTSB investigators turned to the cockpit voice recorder of Avjet 303 Golf Alpha
29:56to understand why the pilots chose to land instead of diverting.
30:01We could learn about the crew's decision-making and what they were doing from their conversations with each other,
30:07you 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.
30:28Hey, 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?
30:42So, 14 minutes before the crash, they're ridiculing another pilot who tried to land without the runway in sight.
30:50Why did they do the same thing?
30:53At that point, they were still in the mode of, we're gonna do this right,
30:58and even sort of made a joke about this one guy that didn't do it right.
31:07Okay.
31:11Okay.
31:11Okay, we'll shoot her from here.
31:13I mean, we're here, but we only get to do it once.
31:16Alright, once.
31:17And then we get a rifle, right?
31:19Yeah, it's too late in the evening to come around.
31:26So, right there, they're talking about doing a missed approach.
31:30That 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
31:48in,
31:48and they were having a conversation about this.
31:50They mentioned again, well, we might only have one shot at this and we have to go to rifle.
31:54They were really saying the right things.
32:00Attention all aircraft. Last aircraft went missed.
32:05What? You went missed.
32:08You went missed?
32:09Damn.
32:11That's not good.
32:16Nine minutes from crashing.
32:19They know the plane in front of them couldn't land.
32:22And they know it's a bad sign for them.
32:26That clearly had to put some pressure on them.
32:28Say, alright, this is, uh, this is not looking good.
32:32It should have those pilots starting to get into the mindset of executing the missed approach, rather than landing the
32:39aircraft.
32:40So, they know they shouldn't attempt the landing either.
32:43Up until now, they've been doing everything right by the book.
32:45Yeah.
32:47I wonder what changed.
32:51Investigators discover something unusual in the CVR transcripts.
32:56Huh.
32:59Looks 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.
33:11Thank you very much.
33:20You think it's the client?
33:24It's possible.
33:28Having somebody else up on the flight deck as you're conducting an approach into a mountainous area at night, in
33:37poor 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 gone 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.
34:08Oh, really?
34:10Oh, really?
34:14The 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, um, is just
34:26such 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.
34:399-8 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
34:51runway.
34:52It's too dangerous to land on that runway under these conditions.
34:56So what happened?
35:04Are we cleared to land?
35:06Not, not yet.
35:07We just missed. The guy in front of us didn't make it either.
35:11Oh, really?
35:16Okay, 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
35:29was a warning shot.
35:31Get this thing in Aspen.
35:34But the pilots still had one more chance to implement their backup plan to divert to another airport.
35:44Where's it at?
35:46Where's it at?
35:47So obviously they still can't see the runway.
35:53To the right. To the right.
36:01So 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. Might they have seen something they thought was the runway?
36:13You know, some lights of the village or whatnot. They believed they saw the runway, but that wasn't correct.
36:19They just keep flying lower and lower looking for the airport.
36:24They were just under way too much pressure to make good decisions.
36:31They had the night curfew. They 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
36:43the ground.
36:45500.
36:46Rev plus 5.
36:5222 seconds after crossing the missed approach point, Avjet 303 Golf Alpha hits the ground.
37:26So, in Los Angeles, they were ready to divert.
37:31Then they get chewed out for talking about diverting and 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.
37:48Sadly, they turned into 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 they descended too low.
38:19Despite the pressures the pilots were under to land, there was one more safeguard that could have prevented this tragedy.
38:27You're not going to believe this.
38:39Investigators of Avjet 303 Golf Alpha examine a safety notice for Aspen Airport that might have prevented the crash.
38:48A NOTAM.
38:51NOTAM 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, a navigation aid is out, all sorts of things.
39:08Two 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.
39:25It said that circling not authorized at night.
39:30This approach is only a circling approach, even if you elect to land straight in.
39:35It actually had the effect of making that approach not authorized at night.
39:42The crash was at 7.02 PM. 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.
40:06It 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?
40:16Notams 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
40:26to the runways closed and everything in between.
40:29And what about the controller?
40:35NOTAMs are also distributed to ATC facilities.
40:38They 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,
40:58fax.
40:59And for whatever reason, didn't get sent to the ATC facilities that needed to know.
41:05Had the controller received the NOTAM, it might have prevented the crash.
41:11In the final analysis, investigators conclude the probable cause of the accident
41:16was the flight crew's operation of the airplane below the minimum descent altitude
41:21without an appropriate visual reference to the runway.
41:26This accident happened because the captain did not go around, did not conduct a missed approach.
41:33Had he done that, they would have gone to rifle.
41:38And the passengers may have been frustrated, may have been angry.
41:41There might have been a big conversation, but they would have been alive.
41:49Investigators 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.
42:13As a result of this accident, Avjet restricts flying into Aspen between sunset and sunrise.
42:20The FAA also revises its specifications for flying into Aspen,
42:25with a minimum visibility of 5 miles,
42:28and a cloud ceiling of at least 4,400 feet above ground now required for landing.
42:36You see the runway?
42:38This is to ensure pilots always have a clear view of the runway before landing.
42:44Thank 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.
43:07Well, the NTSB has also made a number of recommendations on improving the NOTAM system,
43:12making things a little bit more graphical and easy to use so that people can sort them out, rather than
43:17just reading a list.
43:19The lessons serve as a warning to all other pilots who interact with passengers.
43:26I think the message of this flight is there is no dinner, date engagement, or birthday party that is more
43:35important 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.
43:45They're not pilots, and they do not know that their behavior is endangering their very lives.
43:51But it did help change the law and change how the FAA operates in many aspects, and for that we're
43:58thankful.
44:30We'll see you next time.
44:31See you next time.