2 fatalities

1996-12-24: Learjet 35 (N388LS) — Aircraft Charter Group — Lebanon, United States of America

Lebanon, United States of AmericaLanding (descent or approach)

On December 24, 1996, a Learjet 35 (registration N388LS) operated by Aircraft Charter Group was involved in an aviation accident near Lebanon, United States of America during landing or approach. 2 people were killed. Investigators recorded the probable cause as: 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 stepdown fix passage, which resulted in an early descent into rising terrain. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 6 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781206423Data APIEditorial standards
Aircraft registered N388LS
Aircraft registered N388LS. Photo: Windmemories / CC BY-SA 4.0, via Wikimedia Commons

During a positioning flight, a crew attempted an ILS approach but strayed off course. After a missed approach, they flew a VOR approach with errors, descending prematurely into rising terrain and colliding with trees.

Flight and Crew Actions

The first officer occupied the left seat and was flying the airplane, while the captain was in the right seat for a positioning flight. As the flight approached its destination, the crew briefed and attempted an ILS RWY 18 approach. The captain reported not receiving the localizer, but the airplane was actually about 5 nautical miles left of the localizer course. Winds at the airport at that time were from 190 degrees true at 5 knots, while 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.

Approach and Navigation Issues

After the missed approach, the captain requested and received clearance for the VOR RWY 25 approach. As the airplane neared the VOR, the captain partially briefed the approach to the first officer, then "talked through" remaining phases 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 while 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 in the wrong direction. When the proper heading was 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 to 2,900 feet, although the procedure required maintaining a minimum of 4,300 feet until joining the inbound course to the VOR. During the inbound portion, the captain amended the altitude to 3,000 feet. As the airplane neared the inbound course, the captain called out the outer marker. The first officer agreed, and the captain stated they could descend to 2,300 feet. The first officer noted that the VOR indications were fluctuating; the captain pointed out continued reception, but the first officer said, "but it's all over the place." Shortly after, the first officer stated he was descending to 2,300 feet.

Collision and Aftermath

Three seconds after the first officer announced the descent to 2,300 feet, the airplane impacted trees and then terrain. The wreckage was located at the 2,300-foot level on rising mountainous terrain, at 061 degrees magnetic, 12.5 nautical miles from the VOR. This point was 10.3 nautical miles prior to where a descent to 2,300 feet was authorized. No evidence was found that the crew used available DME information. There was also no evidence of pre-impact mechanical malfunction.

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 stepdown 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.