NYC97FA194

NTSB accident investigation · Learjet 35A · Dorchester, NH · December 24, 1996

Accident · FatalField investigationFinal report
Date
December 24, 1996, 10:05 local (15:05 UTC)
Place
Dorchester, NH
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N388LSLearjet 35A
Weather
Instrument (IMC) · Day
Status
Completed · report December 7, 2000
Report
Approved by Office Director
FAA report
19961224040119A
Case key
47757

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterApproach - iaf to faf/outer marker (ifr)
Became lost/disorientedPilot in commandCause
Navaid signal - misjudgedFlightcrewCause
Descent - prematureFlightcrew
Ifr procedure - misreadPilot in commandFactor
Crew/group briefing - inadequateFlightcrewFactor
Self-induced pressureFlightcrewFactor
Compensation for wind conditions - not usedFlightcrewFactor
Improper use of equipment/aircraftFlightcrewFactor

Analysis

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.

Factual narrative

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 controll

Aircraft

Registration
N388LS
Reported as
Learjet 35A
Category
Airplane
Serial number
388
Airframe hours
6,897
Engine
Garrett TFE 731, 3,500 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Aircraft Charter Group, Inc.
Registered owner
Airland LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · November 26, 1996 · 143 hours before
Departed
BDR · Bridgeport, CT
Destination
LEB · Lebanon, NH
Flight plan
IFR
Airport
LEB · Lebanon Municipal Airport, runway 25, 5,496 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
4,250 total · 1,000 in this make and model · 3,058 as pilot in command · 55 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
190° at 5 knots
Visibility
5 statute miles
Lowest ceiling
1,200 ft overcast
Temperature
106 °F, dew point 99 °F
Altimeter
29.00 inHg
Observed at
LEB, 17 nm away

Docket · 33

The files NTSB released with the investigation on April 19, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 32.1 MB in all.

Pilot-operator aircraft accident report NTSB form 61201-2Item 1 · PDF · 5 pages · 334 KBInstrument approach and visual charts for lebanon NHItem 2 · PDF · 7 pages · 1.8 MBATC packageItem 3 · PDF · 113 pages · 6.0 MBCopy of captain's resume provided when hired with operatorItem 4 · PDF · 1 page · 113 KBExcerpt from FAA regulations 14 CFR part 91 91207 regarding emergency locator transmittersItem 5 · PDF · 2 pages · 140 KBEquipment list for N388LSItem 6 · PDF · 3 pages · 143 KBMaintenance records of installation of the trimble 2101 approach 6PS navigation system and a copy of the trimble 2101 faItem 7 · PDF · 17 pages · 1.1 MBSurface weather observation report for lebanon NHItem 8 · PDF · 1 page · 133 KBWitness information provided by state of NH fish and game departmentItem 9 · PDF · 59 pages · 2.4 MBCaptain's training records provided by operatorItem 10 · PDF · 39 pages · 2.4 MBCo-pilot's training records provided by operatorItem 11 · PDF · 25 pages · 1.2 MBExcerpts from the operator's operational manualItem 12 · PDF · 22 pages · 1.2 MBWitness information provided by brattleboro policeItem 13 · PDF · 4 pages · 252 KBCopy of invoice for data cord installed in trimble 2101 6PSItem 14 · PDF · 1 page · 261 KBIFR low altitude enroute chart excerptItem 15 · PDF · 1 page · 308 KBLetter to FAA assigning captain as new chief pilot and the previous chief pilot's resignation letterItem 16 · PDF · 2 pages · 95 KBFlight safety international records of recurrent training for the captainItem 17 · PDF · 6 pages · 345 KBOperator's management history provided by the operatorItem 18 · PDF · 1 page · 12 KBCopy of captain's resume provided by previous employerItem 19 · PDF · 2 pages · 127 KBWeather report from NWSItem 20 · PDF · 59 pages · 3.4 MBThree weather briefings obtained by captainItem 21 · PDF · 37 pages · 1.1 MBRadar data from FAAItem 22 · PDF · 57 pages · 4.9 MBRadar plot by NTSB hqItem 23 · PDF · 14 pages · 1.2 MBRecorded radar studyItem 24 · PDF · 13 pages · 617 KBCockpit voice recorder 12-factual report of group chairmanItem 25 · PDF · 50 pages · 1.5 MBMaterials laboratory 15-factual reportItem 26 · PDF · 4 pages · 94 KBStatement of party representatives to NTSB investigationItem 27 · PDF · 1 page · 65 KBRelease of aircraft wreckage NTSB form 612015Item 28 · PDF · 2 pages · 97 KBCockpit voice recorder waveform studyItem 29 · PDF · 6 pages · 210 KBCollins ADF-60 operations manual excerptItem 30 · PDF · 1 page · 45 KBMemorandums for the recordItem 31 · PDF · 2 pages · 31 KBFAA flight inspection reportsItem 32 · PDF · 4 pages · 298 KBReceipt for return of airspeed indicatorsItem 33 · PDF · 1 page · 66 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.