Pilot error and fatigue: 2004 Gulfstream crash

On November 22, 2004 a chartered Gulfstream III aircraft crashed in poor weather while on ILS approach to Houston's Hobby Airport. The aircraft was being repositioned from Dallas Love Field to Houston where it was scheduled to pick up former President George H. W. Bush and several other passengers. At the time of the accident, two pilots and a flight attendant were aboard the aircraft, and all three perished.

The National Transportation Safety Board (NTSB) has just released its report on the accident. As is true of every NTSB report, this one is a fascinating read. The brief cites this as the probable cause of the accident:

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's failure to adequately monitor and cross-check the flight instruments during the approach. Contributing to the accident was the flight crew's failure to select the instrument landing system frequency in a timely manner and to adhere to approved company approach procedures, including the stabilized approach criteria.

While not listed as part of 'probable cause,' the report also gives mention to fatigue issues:

Fatigue might have also played a role in the flight crew's degraded situational awareness. According to the captain's wife, on the night before the accident, the captain received about 4 hours less sleep than normal. A company employee stated that, when the captain arrived for work on the morning of the accident, he looked as though he had just woken up. The first officer's wife stated that the first officer did not have regular sleeping hours and that she was not sure how much sleep he got the night before the accident. Although the early reporting time for the accident flight might have resulted in flight crew fatigue, the actual amount and quality of sleep received by the captain and the first officer could not be determined. Regardless, their improper conduct of the approach reflected fundamental operational shortcomings that were independent of fatigue.

Read the NTSB Aircraft Accident Brief here: Crash During Approach to Landing, Business Jet Services, Ltd., Gulfstream G-1159A (G-III), N85VT, Houston, Texas, November 22, 2004 - NTSB Aircraft Accident Brief

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