Turbine Pilot

A long-lost Lear gives up its secrets

On a chilly and sullen winter's day, a Learjet 35A with a crew of two pilots inexplicably disappeared while executing a nonprecision VOR instrument approach to Lebanon Municipal Airport, Lebanon, New Hampshire. It was Christmas Eve, 1996, and for family and friends of the crew, what began as the cruelest of winters was only the prelude to a long wait to find the missing aircraft. Massive searches were organized to no avail. With each changing season, speculation grew as to the whereabouts of Learjet N388LS. Nearly three years would pass before the mystery was solved. In November 1999, a hiker discovered the wreckage in a remote wooded area. The jet had struck a mountain at an elevation of 2,300 feet. The aircraft was about 1.2 miles right of the final approach course and more than 10 miles outside of where the instrument approach procedure allowed descent to that altitude.

Three weeks before the accident and only a few days after receiving a type rating in the Learjet, the captain was promoted from first officer to chief pilot of the small FAR Part 135 charter company. He was the latest in a string of short-term chief pilots, the eighth in just five years, in fact. The previous one had resigned over what he perceived as management's sometimes-unsafe dispatch and scheduling practices. At the time of the accident, the captain had accumulated more than 800 hours of jet time, mostly in Learjets, and about 4,250 total flight hours. The first officer had logged 2,067 total flight hours, including 268 second-in-command (SIC) hours in turbojet aircraft.

But flight time totals tell only part of the story. The new captain had logged much of his SIC Lear time with a particular "my way or the highway" captain who openly discouraged assertiveness from his first officers, even in the face of obvious danger. On one flight this more senior pilot ran so low on fuel that the Lear's low-fuel pressure light illuminated before landing. This after he had ignored a different first officer's plea to divert. On another flight this captain actually ran out of fuel while taxiing in after landing.

The Learjet 35A is a high-performance aircraft that is certified with a two-pilot crew, and there's a reason for that. It demands consistent use of standard procedures and good crew coordination on any flight. But when shooting a nonprecision instrument approach in mountainous terrain, these crew attributes are indispensible. Simulator training is widely recognized as an effective way to develop these habits, and many corporate flight departments provide this rigorous training to their pilots. A new captain candidate, even one with extensive first officer experience in the aircraft, typically undergoes a two-week course of simulator and ground school instruction at a training facility such as FlightSafety International, leading to a type rating. During this time he or she receives about 25 hours of simulator instruction and 40 hours of ground instruction. Periodic refresher simulator training then follows each year. However, the Federal Aviation Regulations don't mandate simulator training, and it is possible to get a type rating with much less cockpit training time, real or simulated.

In this case, the captain received his "in-house" type rating after just a single training flight in the company Learjet, followed by an FAA-observed checkride. About 14 months prior to the accident, he did attend a five-day recurrent Learjet course at FlightSafety International's Wichita Learning Center. His instructor commented then on his below-average aircraft control, poor instrument scan, and difficulty with Learjet systems operations and checklist procedures. But by the end of the course, the instructor felt his performance had risen to meet standards. This was the first and only simulator training he received in the Learjet 35.

The first officer of the ill-fated flight never received any. He was described by pilots who knew him as an enthusiastic but not especially assertive pilot. The Christmas Eve flight was the first time the two were paired as a crew.

The accident flight originated as a repositioning flight without passengers from Igor I. Sikorsky Memorial Airport in Bridgeport, Connecticut. The first officer was flying the aircraft from the left seat, a common practice at many charter companies when no passengers are on board. It is believed that the pilots shared a single set of approach charts.

The straight-line distance between Igor I. Sikorsky Memorial and Lebanon Municipal is only 152 nautical miles, and not much farther as flown on airways. At Learjet speeds, the flight from start to finish would take about 35 minutes, and the crew would be busy throughout.

The weather at Lebanon Municipal was not especially bad, with visibility of five miles beneath a 1,200-foot overcast ceiling. At the surface, a light wind blew from the south at 5 knots, but the winds aloft were much stronger. At 6,000 feet the area winds were predicted to be from 220 degrees in excess of 40 kt. The ILS to Runway 18 was in use, but radar coverage was limited because of mountainous terrain. Therefore, instead of a radar vector to the final approach course, Boston Center cleared the crew to an initial approach fix from which they began the procedure. This included a procedure turn to allow them to reverse course and align the aircraft with the runway without controller assistance.

The approach did not go well. After maneuvering on their own to join the localizer, the crew became confused about their position. They reported to the Tower that they were inbound at BURGR, the final approach fix on the localizer course, but were "unable to receive the localizer." At the time, they were actually five miles southeast of BURGR, probably well outside the area of localizer reception. The Tower advised them that the localizer was showing "in the green." They missed the approach and requested the VOR approach to Runway 25, with a circle to land on Runway 18.

The crew was sent direct to the Lebanon Municipal VOR from the southeast, told to cross it at or above 4,700 feet msl, and was cleared for the second approach. Implied in this clearance was the need to maintain safe altitudes, as detailed in FAR 91.175, "Takeoff and Landing Under IFR." In short, this regulation states that once an approach clearance is received, a pilot must maintain the last altitude assigned until established on an identifiable segment of a route or approach procedure that allows descent to a lower altitude.

In this case there were four distinct step-down altitudes to be met. The aircraft could descend to 4,300 feet upon crossing the VOR and after becoming established on the published outbound course of 66 degrees. While remaining within 10 miles or less of the station, the aircraft would reverse course in a procedure turn and intercept the reciprocal inbound course of 246 degrees back to the VOR. Once established on this course, the flight could maintain 2,900 feet until reaching Hanover (LAH) NDB, when further descent to 2,300 feet was allowed. Passing the VOR, descent to the circle-to-land minimum descent altitude of 1,720 feet was permitted.

The approach chart depicted several prominent obstructions, including a 3,238-foot mountain peak outside of the 10-mile protected airspace and near the extended final approach course, and a 2,341-foot tower just outside of the step-down fix at the Hanover NDB.

Company procedure for flying nonprecision approaches in the Lear called for slowing to 200 kt or less and setting approach flaps at 8 degrees when crossing the initial approach fix outbound, in this case the Lebanon Municipal VOR. After completing the procedure turn and becoming established inbound, flaps should be set to 20 degrees and the gear lowered. Flaps should be set to 40 degrees passing the final approach fix inbound, also the VOR in this case. This routine keeps speed in check, allows for a more predictable and stabilized approach, and makes it easier to stay within protected airspace.

Almost immediately, things began to unravel. At one point the pilots believed themselves to be passing the VOR outbound, then realized it was the airport, located about 4.5 miles southwest of the VOR that they were passing. (This was possibly in reference to waypoints stored in the aircraft's GPS.) They finally crossed over the VOR at 2:59:23 p.m. and began the approach.

The first officer was flying, but apparently only the captain had the approach chart in front of him. Not having previously briefed this approach, there followed a game of "20 Questions" as the first officer queried the captain about headings and altitudes to fly. Unfortunately, the captain's responses were often incorrect. At 3:01:29 p.m., more than two minutes after beginning to track outbound, the captain instructed the first officer to "go to a heading of two-two-one" to begin the procedure turn. Shortly afterward he repeated this instruction, but when the first officer read back the heading, the captain corrected himself to a heading of "zero-two-one for one minute." When asked which altitude to descend to, the captain correctly indicated 2,900 feet once established on the inbound course, then erroneously reversed himself, saying, "We can go down to twenty-nine now."

Meanwhile, the aircraft was still tracking outbound from the VOR, for nearly three minutes, in fact, before it was slowed and 8 degrees of approach flaps were set. With the brisk tailwind aloft, the Lear's high groundspeed was rapidly taking it beyond the 10-mile protected airspace (by now the aircraft was no longer in radar contact). Neither pilot made mention of their increasing DME distance from the VOR. At 3:03:15 p.m., almost four full minutes after passing the VOR, they turned inbound.

At 3:04:18 the captain noted the inbound VOR course alive, then at 3:04:46 remarked, "There's the outer marker right there," an apparent reference to crossing the LAH NDB. In fact, they were many miles northeast of LAH at this point. It is possible the ADF needle swung to the three o'clock parked position as the signal became blocked by terrain, causing the captain to misinterpret this movement as station passage. But LAH also could be identified as the 2.2 DME fix, a cross-check that neither pilot made. In any case, the captain advised the first officer a few seconds later, at 3:04:49, "OK, we can go down to twenty-three."

At 3:04:54 the crew began a half-minute discussion about the VOR signal, which had become increasingly erratic and at one point was lost altogether (this signal, too, probably was blocked by terrain). Despite uncertainty about the course guidance, the first officer reported at 3:05:25 he was "going down to twenty-three." Three seconds later, the Lear hit the mountain.

The NTSB determined the probable causes of the accident to be the captain's failure to maintain situational awareness and the crew's resulting misinterpretation of step-down fixes. Contributing factors included the captain's misreading of the approach plate, the crew's hurried and incomplete approach briefings, failure to use all available navigation aids, and their failure to account for the tailwind at altitude during execution of the VOR approach.

The complete record of this accident paints a clear picture of a breakdown of crew coordination and basic operating procedures during a high-workload flight. Yet, "Why?" remains its most troubling aspect. It's tempting to lay some blame at least at the feet of a corporate culture that provided legal but arguably inadequate training to this junior crew. More rigorous simulator-based training might have hammered home the importance of good crew resource management and observance of standard operating procedures. Or more "seasoning" under captains who encouraged teamwork might have ingrained these good habits. Ultimately, though, the crew should have recognized their tenuous position and done something about it.

Failure to follow procedures, fully brief an approach, or clear up uncertainties doesn't always or even usually result in disaster. But when that little voice in our head tells us something isn't Ruite right, no matter what our experience level, it's time to sit up and ask why.

Vincent Czaplyski flies as a Boeing 737 captain for a major U.S. airline.