# NTSB NYC97FA194: Learjet 35A, N388LS, Dorchester, NH, December 24, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 24, 1996, 10:05 local (15:05 UTC) - Place: Dorchester, NH - Location: 43.8232° N, 72.0108° W: Placed by OpenAirDocs from NTSB’s distance and direction from LEBANON MUNI (LEB), within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=43.8232&lon=-72.0108&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 7, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 47757 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC97FA194 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47757/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=47757 - Page: https://openairdocs.org/ntsb/NYC97FA194 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - iaf to faf/outer marker (ifr) - became lost/disoriented, pilot in command (cause) - navaid signal - misjudged, flightcrew (cause) - descent - premature, flightcrew - ifr procedure - misread, pilot in command (contributing factor) - crew/group briefing - inadequate, flightcrew (contributing factor) - self-induced pressure, flightcrew (contributing factor) - compensation for wind conditions - not used, flightcrew (contributing factor) - improper use of equipment/aircraft, flightcrew (contributing factor) ## 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](https://openairdocs.org/deregistered/N388LS-1998-05-08), registration cancelled 1998-05-08, S/N 388 (OpenAirDocs) - Reported make and model: Learjet 35A - Registry model: [Gates Learjet 35A](https://openairdocs.org/model/gates-learjet-35a) (registry code 5170602) (OpenAirDocs) - Category: Airplane - Serial number: 388 - Airframe hours: 6897 - Engines: Garrett TFE 731 3500 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19961224040119A](https://openairdocs.org/incident/19961224040119A), Dec 24, 1996: Lear 35A, Lebanon, NH, Destroyed, 2 fatal. Became missing on initual VOR approach. ## Docket (33 files) The files NTSB released with the investigation on April 19, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=47757. 32.1 MB in all. - Pilot-operator aircraft accident report NTSB form 61201-2 (item 1, PDF, 5 pages, 334 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13642085&FileExtension=pdf&FileName=Pilot-Operator%20Aircraft%20Accident%20Report%20NTSB%20Form%2061201-2-Master-Rel.pdf - Instrument approach and visual charts for lebanon NH (item 2, PDF, 7 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13642357&FileExtension=pdf&FileName=Instrument%20approach%20and%20visual%20charts%20for%20Lebanon%20NH-Master-Rel.pdf - ATC package (item 3, PDF, 113 pages, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13642751&FileExtension=pdf&FileName=ATC%20Package-Master-Rel.pdf - Copy of captain's resume provided when hired with operator (item 4, PDF, 1 page, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643329&FileExtension=pdf&FileName=Copy%20of%20captain%27s%20resume%20provided%20when%20hired%20with%20operator-Master-Rel.pdf - Excerpt from FAA regulations 14 CFR part 91 91207 regarding emergency locator transmitters (item 5, PDF, 2 pages, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643332&FileExtension=pdf&FileName=Excerpt%20from%20FAA%20regulations%2014%20CFR%20Part%2091%2091207%20regarding%20Emergency%20locator%20transmitters-Master-Rel.pdf - Equipment list for N388LS (item 6, PDF, 3 pages, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643252&FileExtension=pdf&FileName=Equipment%20list%20for%20N388LS-Master-Rel.pdf - Maintenance records of installation of the trimble 2101 approach 6PS navigation system and a copy of the trimble 2101 fa (item 7, PDF, 17 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643290&FileExtension=pdf&FileName=Maintenance%20records%20of%20installation%20of%20the%20Trimble%202101%20approach%206PS%20navigation%20system%20and%20a%20copy%20of%20the%20Trimble-Master-Rel.pdf - Surface weather observation report for lebanon NH (item 8, PDF, 1 page, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643139&FileExtension=pdf&FileName=Surface%20weather%20observation%20report%20for%20Lebanon%20NH-Master-Rel.pdf - Witness information provided by state of NH fish and game department (item 9, PDF, 59 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643444&FileExtension=pdf&FileName=Witness%20Information%20provided%20by%20State%20of%20NH%20Fish%20and%20Game%20Department-Master-Rel.pdf - Captain's training records provided by operator (item 10, PDF, 39 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643730&FileExtension=pdf&FileName=Captain%27s%20training%20records%20provided%20by%20operator-Master-Rel.pdf - Co-pilot's training records provided by operator (item 11, PDF, 25 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643898&FileExtension=pdf&FileName=Co-Pilot%27s%20training%20records%20provided%20by%20operator-Master-Rel.pdf - Excerpts from the operator's operational manual (item 12, PDF, 22 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643736&FileExtension=pdf&FileName=Excerpts%20from%20the%20Operator%27s%20Operational%20Manual-Master-Rel.pdf - Witness information provided by brattleboro police (item 13, PDF, 4 pages, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13642802&FileExtension=pdf&FileName=Witness%20information%20provided%20by%20Brattleboro%20Police-Master-Rel.pdf - Copy of invoice for data cord installed in trimble 2101 6PS (item 14, PDF, 1 page, 261 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13644103&FileExtension=pdf&FileName=Copy%20of%20invoice%20for%20data%20cord%20installed%20in%20Trimble%202101%206PS-Master-Rel.pdf - IFR low altitude enroute chart excerpt (item 15, PDF, 1 page, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13644950&FileExtension=pdf&FileName=IFR%20low%20altitude%20enroute%20chart%20excerpt-Master-Rel.pdf - Letter to FAA assigning captain as new chief pilot and the previous chief pilot's resignation letter (item 16, PDF, 2 pages, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13670279&FileExtension=pdf&FileName=Letter%20to%20FAA%20assigning%20Captain%20as%20new%20chief%20pilot%20and%20the%20previous%20chief%20pilot%27s%20resignation%20letter-Master-Rel.pdf - Flight safety international records of recurrent training for the captain (item 17, PDF, 6 pages, 345 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13670326&FileExtension=pdf&FileName=Flight%20Safety%20International%20records%20of%20recurrent%20training%20for%20the%20Captain-Master-Rel.pdf - Operator's management history provided by the operator (item 18, PDF, 1 page, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13669831&FileExtension=pdf&FileName=Operator%27s%20management%20history%20provided%20by%20the%20operator-Master-Rel.pdf - Copy of captain's resume provided by previous employer (item 19, PDF, 2 pages, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13669780&FileExtension=pdf&FileName=Copy%20of%20Captain%27s%20resume%20provided%20by%20previous%20employer-Master-Rel.pdf - Weather report from NWS (item 20, PDF, 59 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13669783&FileExtension=pdf&FileName=Weather%20Report%20from%20NWS-Master-Rel.pdf - Three weather briefings obtained by captain (item 21, PDF, 37 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13669580&FileExtension=pdf&FileName=Three%20weather%20briefings%20obtained%20by%20captain-Master-Rel.pdf - Radar data from FAA (item 22, PDF, 57 pages, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13671059&FileExtension=pdf&FileName=Radar%20data%20from%20FAA-Master-Rel.pdf - Radar plot by NTSB hq (item 23, PDF, 14 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13671013&FileExtension=pdf&FileName=Radar%20plot%20by%20NTSB%20HQ-Master-Rel.pdf - Recorded radar study (item 24, PDF, 13 pages, 617 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13671062&FileExtension=pdf&FileName=Recorded%20Radar%20Study-Master-Rel.pdf - Cockpit voice recorder 12-factual report of group chairman (item 25, PDF, 50 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13671066&FileExtension=pdf&FileName=Cockpit%20Voice%20Recorder%2012-Factual%20Report%20of%20Group%20Chairman-Master-Rel.pdf - Materials laboratory 15-factual report (item 26, PDF, 4 pages, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13671146&FileExtension=pdf&FileName=Materials%20Laboratory%2015-Factual%20Report-Master-Rel.pdf - Statement of party representatives to NTSB investigation (item 27, PDF, 1 page, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13670880&FileExtension=pdf&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master-Rel.pdf - Release of aircraft wreckage NTSB form 612015 (item 28, PDF, 2 pages, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13670763&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage%20%20NTSB%20Form%20612015-Master-Rel.pdf - Cockpit voice recorder waveform study (item 29, PDF, 6 pages, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13670884&FileExtension=pdf&FileName=Cockpit%20Voice%20Recorder%20Waveform%20Study-Master-Rel.pdf - Collins ADF-60 operations manual excerpt (item 30, PDF, 1 page, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13671166&FileExtension=pdf&FileName=Collins%20ADF-60%20Operations%20Manual%20Excerpt-Master-Rel.pdf - Memorandums for the record (item 31, PDF, 2 pages, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13670580&FileExtension=pdf&FileName=Memorandums%20for%20the%20Record-Master-Rel.pdf - FAA flight inspection reports (item 32, PDF, 4 pages, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13670888&FileExtension=pdf&FileName=FAA%20Flight%20Inspection%20Reports-Master-Rel.pdf - Receipt for return of airspeed indicators (item 33, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13671172&FileExtension=pdf&FileName=Receipt%20for%20Return%20of%20Airspeed%20Indicators-Master-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.