DORCHESTER, NH, USA
N388LS
Learjet 35A
The first officer was in the left seat, flying the airplane, and the captain was in the right seat, for the positioning flight. Approaching the destination, the crew briefed, then attempted an ILS RWY 18 approach. The captain reported not receiving the localizer, when, in fact, the airplane was actually about 5 nautical miles to the left of it. Winds at the airport, about that time, were from 190 degrees true, at 5 knots; however, area winds at 6,000 feet were from 220 degrees, in excess of 40 knots. The crew executed a missed approach, but did not follow the missed approach procedures. The captain later requested, and received clearance for, the VOR RWY 25 approach. The captain partially briefed the approach to the first officer as the airplane neared the VOR, then subsequently "talked through" remaining phases of the approach as they occurred. The outbound course for the VOR RWY 25 approach was 066 degrees, and the minimum altitude outbound was 4,300 feet. After passing the VOR, the captain directed the first officer to maintain 4,700 feet. The airplane's last radar contact occurred as the airplane was proceeding outbound, 7 nautical miles northeast of the VOR, at 4,800 feet. As the airplane approached the course reversal portion of the procedure turn, the captain initially directed the first officer to turn the airplane in the wrong direction. When the proper heading was finally given, the airplane had been outbound for about 2 minutes. During the outbound portion of the course reversal, the captain told the first officer to descend the airplane to 2,900 feet, although the procedure called for the airplane to maintain a minimum of 4,300 feet until joining the inbound course to the VOR. During the inbound portion of the course reversal, the captain amended the altitude to 3,000 feet. As the airplane neared the inbound course to the VOR, the captain called out the outer marker. The first officer agreed, and the captain stated that they could descend to 2,300 feet. The first officer then noted that the VOR indications were fluctuating. The captain pointed out the VOR's continued reception, and the first officer noted, "but it's all over the place." Shortly thereafter, the first officer stated that he was descending the airplane to 2,300 feet. Three seconds later, the airplane impacted trees, then terrain. The wreckage was located at the 2,300-foot level, on rising mountainous terrain, 061 degrees magnetic, 12.5 nautical miles from the VOR. It was also 10.3 nautical miles prior to where a descent to 2,300 feet was authorized. There was no evidence that the crew used available DME information. There was also no evidence of pre-impact mechanical malfunction.
HISTORY OF FLIGHT On December 24, 1996, at 1005 Eastern Standard Time, a Learjet 35A, N388LS, operated by Aircraft Charter Group Inc., was destroyed when it impacted terrain near Dorchester, New Hampshire. At the time of the accident, the airplane was in instrument meteorological conditions, conducting an instrument approach to the Lebanon Municipal Airport (LEB), Lebanon, New Hampshire. The captain and the first officer, both of whom were certificated airline transport pilots, were fatally injured. An instrument flight rules flight plan had been filed for the flight, from Igor I. Sikorsky Memorial Airport (BDR), Bridgeport, Connecticut, to Lebanon. The positioning flight was conducted under 14 CFR Part 91. A sequence of events was derived from Boston Air Route Traffic Control Center (ARTCC) communications transcripts, Lebanon Tower communications transcripts, the airplane's cockpit voice recorder (CVR), and radar/transponder beacon information, which was incorporated into a Safety Board Recorded Radar Study. Timelines provided in the tower transcripts lagged those of the center by 22 to 27 seconds. In addition, there were occasional, slight discrepancies between center and CVR timelines (1 second), due to transcription differences. The flight departed Bridgeport at 0919. The captain was in the right seat, and the first officer was in the left seat, flying the airplane. The airplane climbed to flight level 190 per instructions, and then was gradually "stepped down" to 7,000 feet as it neared Lebanon. At 0927:04, the center controller cleared the flight to proceed direct, to Lebanon. About 10 minutes later, the captain copied the ATIS information, then read part of it back to the first officer, and said, "doing the i-l-s approach." At 0937:53, the captain stated to the first officer, "you wanna review this and i'll take the airplane if you like." The first officer responded with, "yeah i will. you can have the airplane." Exactly when control of the airplane was passed back to the first officer, was not determined. At 0938:44, there was an unintelligible conversation, followed, shortly thereafter, by one of the pilots, which one, being unknown, stating, "yeah, we're set up on eleven nine." According to the instrument approach procedure, the ILS RWY 18 approach frequency at Lebanon was 111.9 mhz. At 0939:40, the first officer called for the approach checklist, and the captain responded with the approach items, followed by, "okay, approach set up is complete." At 0941:28, the captain confirmed with the center controller that the crew had weather "information hotel" for Lebanon. At 0945:10, the crew was instructed to maintain a heading of 050 degrees magnetic, and at 0946:06, they were issued a descent from 7,000 feet to 4,700 feet. At 0946:14, the controller stated, "lear eight lima sierra...once you leave five thousand proceed direct burgr for the i-l-s approach," which was acknowledged by the captain. According to the radar data, the airplane was about 1 nautical mile southwest of the Lebanon VOR, heading northeast, at that time. The Lebanon VOR was located 066 degrees magnetic, 4.4 nautical miles from the approach end of Runway 25 at Lebanon Airport. According to the ILS RWY 18 approach procedure, BURGR intersection was identified as an outer marker on the localizer, and was also 6 nautical miles from the Lebanon VOR, on its 317-degree radial. At 0947:21, the airplane was about 3 nautical miles northeast of the Lebanon VOR, descending through 5,500 feet. About that time, the center controller radioed: "and eight eight lima sierra, maintain four thousand seven hundred until established on a portion of the approach, cleared i-l-s approach lebanon." The captain acknowledged both the altitude and the approach clearance, and shortly thereafter, the crew configured the airplane to "flaps eight." According to the radar data, the airplane continued to the northeast, until the last outbound radar contact, at 0947:45. At the time, the airplane was at 4,900 feet. At 0948:35, the controller told the crew that radar service was terminated, and to contact Lebanon Tower. At 0948:52, the captain contacted the Lebanon Tower controller, and reported, "...with you i-l-s one eight inbound, seven out outside of burgr." The tower controller then reported that, "weather remains basically the same. winds are one niner zero at seven now. altimeter two niner eight three." The captain acknowledged the call, then asked if the airplane was cleared to land. The tower controller told him to report BURGR inbound. At 0948:57, radar contact was regained, northwest of the last contact, consistent with the airplane having made a left, teardrop turn. Subsequent radar returns indicated that the airplane then headed southwest. At 0949:57, the airplane was at 4,700 feet, and about 11 nautical miles northeast of Lebanon Airport. At 0949:58, the captain stated to the first officer, "well, i was looking at the ah airport thinking that it was eight miles." The first officer then discussed the amount of flaps deployed, and the captain asked, "you want 'em up?" The first officer said that he did, and right after, at 0950:17, the captain said, "four thousand seven hundred...." Shortly thereafter, he said, "let's get some speed up here." At 0950:41, the first officer stated, "okay, localizer's coming alive," then, "localizer's alive." At 0950:55, the captain stated to the first officer, "what's up with this...," and the first officer then asked, at 0951:16, "tuned and identified, right?" The captain did not answer the question, but at 0951:20, said, "we're not getting a localizer here." At 0951:21, the captain reported to the tower, "...we're burgr inbound we're not getting a localizer." Radar data revealed that the airplane was not at BURGR at that time, but was about 5 nautical miles to the southeast of it, heading southwest. At 0951:29, the tower controller asked if the crew was going to continue the approach or execute a missed approach from that position, and reported that the localizer was "in the green." The captain answered back, "roger." The captain then told the first officer to descend to 3,500 feet. The first officer asked for flaps eight, and the captain answered, "going to eight." At 0952:07, the captain stated, "all right, we've missed, execute missed approach," to which the first officer responded, "okay." At 0952:09, the tower controller asked for the crew's intentions. The captain responded that they were going to execute the missed approach, and, "we're not receiving the localizer." Six seconds later, at 0952:18, the controller said, "roger." The published missed approach for the ILS RWY 18 approach was: "Climb to 2000', then climbing RIGHT turn to 4800' direct IVV NDB and hold." The IVV NDB was the White River NDB, which was located about 8 nautical miles southwest of the Lebanon Airport, with a frequency of 379 khz. At 0952:20, the captain said to the first officer, "missed approach," then told him to "climb to two thousand turn forty eight hundred, direct to the n-d-b." The first officer responded, "all right", and the captain then said, "set three seventy nine, i'll put that in there." At 0952:28, the tower controller told the crew to execute the "...published missed approach, contact boston center...." According to the radar data, at that time, the airplane was about 2 nautical miles southeast of the VOR, proceeding southeast, at approximately 4,500 feet. At 0952:36, the first officer called for "flaps up," and the captain responded with, "flaps up." The first officer then asked, "what's the altitude you want me to go to," to which, the captain first answered, "just climb," then said right after that, "forty seven hundred." At 0952:50, the captain reported to Boston Center that the airplane was "on the missed." The center controller asked for the crew's intentions, and the captain responded with a request for a confirmation that the localizer frequency was 111.9 mhz. The center controller told the captain that he'd check on it, but to fly the "published missed procedure," and maintain 5,000 feet. At 0953:24, the captain acknowledged the instructions to fly the published missed approach procedure at 5,000 feet. According to the radar data, the airplane climbed to 5,000 feet shortly after being cleared to that altitude. However, it did not make a turn to the right, to proceed to the White River NDB, per the published missed approach instructions. Instead, it continued heading to the southeast. At 0953:27, the first officer stated, "this ah this ah i'm not even getting an a-d-f." Seven seconds later, the captain responded with, "here you go." At 0953:35, the center controller confirmed that the localizer frequency had been 111.9 mhz, and the captain reiterated that the crew was unable to receive it. At 0953:50, the captain requested the VOR RWY 25 approach with "circle to land." The controller approved the request, and then, at 0954:19, cleared the airplane to proceed directly to the VOR. According to the radar data, at that time, the airplane was about 9 nautical miles southeast of the Lebanon VOR. The airplane made a right turn from that position, and headed back toward the northwest. According to the VOR or GPS RWY 25 approach procedure in effect at the time, the outbound course from the VOR was 066 degrees magnetic, with a descent down to a minimum of 4,300 feet above mean sea level. The procedure turn was to be completed within 10 nautical miles of the VOR. The published course reversal for the procedure turn included an initial left turn to a heading of 021 degrees magnetic, followed by a right turn to a heading of 201 degrees magnetic, until joining an inbound course to the VOR of 246 degrees magnetic. After joining the inbound course, the approach called for a descent to a minimum of 2,900 feet, until the Hanover NDB/marker beacon, which was on the inbound course, 2.2 nautical miles northeast of the VOR. Upon reaching Hanover, a descent to a minimum of 2,300 feet was authorized, until after passing the VOR. At that time, a descent to the published minimum descent altitude could be made. The Lebanon VOR operating frequency was 113.7 mhz and the Hanover NDB operating frequency was 276 khz. At 0954:24, the captain stated to the first officer, "well let me set you up here. same thing lebanon. three oh four." At 0955:07, the airplane was cleared to cross the Lebanon VOR at or above 4,700 feet, then cleared for the VOR RWY 25 approach. At 0955:19, the captain stated, "three fourteen." The first officer responded with, "no problem.... i'm gonna go outbound on the zero six six radial and...here." At 0955:52, the captain stated: "three one eight," then repeated it twice more. At 0956:04, the captain stated, "let me get rid of this thing," and shortly thereafter, stated, "it'll probably make things easier for you." At 0956:16, the captain said, "i'll take our time outbound," and at 0957:08, stated, "okay that's gonna be our outbound zero zero six. go off lebanon." At 0957:43, the center controller stated, "...radar service is terminated contact lebanon tower now one two five point niner five." The captain rogered, and contacted Lebanon Tower, "on the v-o-r two five circle to land one eight." The tower controller then requested the airplane's position, and at 0958:07, the captain answered back, "...we're ah five miles to the ah southeast of the v-o-r." According to the radar data, when the captain called the 5 miles, the airplane was about 5 nautical miles to the southeast of the VOR. The tower controller then told the crew to report "v-o-r outbound." He also stated, "...i'll give you a wind check ah in the vicinity of the v-o-r inbound. winds are currently two three zero at five...." He then gave them the option to land on Runway 25 instead of Runway 18, which they accepted. At 0958:41, the first officer called, "over station passage." However, at that time, the airplane was about 2 nautical miles south of the Lebanon VOR, inbound. The captain immediately responded with, "yeah...this is the airport that's the v-o-r. they're not on the field." The first officer responded with, "oh, I see," and the captain continued with: "...just to let you know." At 0958:47, the first officer stated, "i might as well start turning now," and 1 second later, asked: "zero zero six?" At 0959:39, the captain stated, "all right now, inbound heading is two forty six. keep...on the turn." At 0959:46, the first officer asked, "two forty six?" and the captain responded, "the inbound. remember we've got to go outbound." The first officer then said, "yeah." At 0959:52, the captain called, "okay, station passage, time is set." According to the radar data, when the captain called station passage, the airplane had just passed over the VOR. At 0959:55, the captain reported, over the radio, "...v-o-r outbound," and the controller requested that they report the VOR inbound. The first officer then asked the captain, "down to what alt?", and the captain responded, at 1000:04, with "zero six six outbound..." At 1000:09, the first officer said, "okay and ah," but the captain cut in at 1000:10 with, "let's go zero six six. grab it. let's go," and the first officer responded with, "zero six six." At 1000:17, the tower controller transmitted, "go ahead maintenance." At 1000:19, the first officer asked, "altitude?", and the captain responded, "four thousand seven hundred. At 1000:27, the tower controller transmitted, over the radio, "maintenance roger." The captain commented to the first officer, "well they're fixing the i-l-s," and the first officer responded, "you bet your...." At 1000:42, the first officer said: "okay time it," and the captain answered, "okay...let's just track back. we have plenty of time. let's just intercept that." Seventeen seconds later, the captain said, "take a big cut into that." At 1001:19, the captain stated, "needle's coming alive." The first officer acknowledged, then the captain stated, "go to a heading of two two one." He repeated the heading of "two two one" 12 seconds later, and told the first officer to "get it around." At 1001:49, the first officer stated, "two two one. altitude?" At 1001:53, the captain said, "no, zero two one. zero two one for one minute," to which, the first officer acknowledged. Elapsed time between the captain calling station passage, and his calling out the corrected course reversal heading, was about 2 minutes. The last recorded radar data for the flight, at 1001:47, indicated that the airplane was about 7 nautical miles northeast of the Lebanon VOR, at 4,800 feet. The average groundspeed outbound was about 230 knots, and the airplane was proceeding along an east, northeasterly ground track. At 1002:04, the captain stated, to the first officer, "...we stay at this altitude until we intercept. then we go down to twenty nine hundred." This was followed at 1002:10, by the captain saying, "we can go down to twenty nine now." At 1002:17, the first officer asked, "right turn or left turn to ah two two one?" At 1002:19, the captain told him it would be a right turn. At 1002:23, the captain said, "two forty six on that...you go to two oh one," which the first officer acknowledged. At 1002:26, the captain stated, "okay and intercept that." The first officer then asked, "and make a right turn in to intercept?" The captain confirmed, "a right turn," and at 1002:32, the first officer stated, "oh okay." The elapsed time between the captain calling station passage, and the first officer's last acknowledgment of the right turn to 221 degrees, was 2 minutes, 40 seconds. At 1002:38, the captain stated, "...approach flaps." At 1002:40, the first officer said, "let me know ah time," and the captain responded with, "'kay you got about fifteen seconds." At 1002:56, the first officer stated, "twenty nine," and at 1003:06, the captain stated, "okay let's turn. maintain three thousand. let's maintain three." The first officer acknowledged the three thousand feet, then, at 1003:15, the captain said, "let's
The captain's failure to maintain situational awareness, which resulted in the airplane being outside the confines of the instrument approach; and the crew's misinterpretation of a step-down fix passage, which resulted in an early descent into rising terrain. Factors included the captain's misreading of the instrument approach procedure, the crew's rushed and incomplete instrument approach briefing, their failure to use additional, available navigational aids, and their failure to account for the winds at altitude.
Source: NTSB Aviation Accident Database
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