NTSB report
At 1805:08, the SCT Woodland controller instructed flight 1455 to “turn left heading one
six zero.” A comparison of the recorded radar data of the accident airplane to 70 other airplanes
that had landed at BUR on runway 8 between 1000 and 2200 on June 13 and 14, 2000, showed
that of the 16 airplanes vectored from the north side of BUR to land on runway 8, 12 were
vectored to intercept the final approach course between 9 and 15 nm west of the runway
threshold. Flight 1455 was given vectors that resulted in interception of the final approach course
about 8 nm west of the runway threshold. This vector put the airplane in an unfavorable position
for final approach, complicated the accident flight crews approach planning and execution, and
contributed to the unstabilized approach.
Further, the controllers restriction to flight 1455 at 1808:19 to “cross Van Nuys at or
above three thousand” was ambiguous. According to the Pilot/Controller Glossary, restrictions
are defined as “[a]n altitude or altitudes, stated in the order flown, which are to be maintained
until reaching a specific point or time. Altitude restrictions may be issued by ATC [air traffic
control] due to traffic, terrain, or other airspace considerations.” The flight was on a160° heading, and crossing over the specific point of Van Nuys was not part of the accident
flights approach. The flight passed abeam of the Van Nuys very high frequency
omni-directional range navigation transmitter by about 2 miles but was not supposed to cross
over Van Nuys. This ambiguous clearance might have caused the flight crew to delay descent
longer than necessary.
In summary, the Safety Board concludes that the actions of the SCT Woodland controller
positioned the airplane too fast, too high, and too close to the runway threshold to leave any safe
options other than a go-around maneuver.
In post-accident interviews, the flight crew told investigators that, during the approach, the
captains navigation radio was tuned to the ILS frequency for runway 8, and the first officers
radio was tuned to the Van Nuys VOR. They indicated that the autopilot was engaged in the
VOR/LOC mode7 and that the airplane captured the localizer course but then overshot the
centerline before correcting back.8 The captain stated to investigators that as the flight passed
about 2 miles west of Van Nuys at 3,000 feet at approximately 220 to 230 knots, he deployed the
speed brakes.
According to the CVR, at 1809:28, when the airplane was at an indicated airspeed of
about 220 knots, the captain called for “flaps five.” At 1809:32, the flaps began to extend.
At 1809:43, the captain called for “gear down.” The captain indicated in a post-accident
interview that at this point in the flight, he noted a 20-knot tailwind indication on the flight
management system (FMS) screen.9 At 1809:53, the BUR tower controller stated, “Southwest
fourteen fifty five, wind uh-two one zero at six [knots], runway eight, cleared to land.”
Simultaneously, the captain called for “flaps fifteen.”10 At 1810:01, the captain again called for
“flaps…fifteen” and “[flaps] twenty five.”
From 1810:24 until 1810:59, the ground proximity warning system (GPWS) alerts were
being continuously broadcast in the cockpit, first as “sink rate” and then, at 1810:44, switching to
“whoop, whoop, pull up.” At 1810:29, the captain stated, “flaps thirty, just put it down.”
At 1810:33, the captain stated, “put it to [flaps] forty. t won’t go, I know that. t’s all right.
[F]inal descent checklist.” After the GPWS “whoop, whoop, pull up” alert sounded at 1810:47,
the captain stated, “that’s all right,” at 1810:53. A final “sink rate” warning was recorded
at 1810:55. The first officer stated in a postaccident interview that instead of reading the final
descent checklist,11 he visually confirmed the checklist items and remembered seeing the captain
arm the ground spoilers. The first officer also stated that when the captain called for flaps 40°,
the airspeed was about 180 knots and went as high as 190 knots during the approach.12 The first
officer indicated that he pointed to his airspeed indicator to alert the captain of the flap limit
speed of 158 knots at flaps 40°.
The captain told Safety Board investigators that he remembered hearing the “sink rate”
warning from the GPWS but that he did not react to the warning because he did not feel that he
had to take action. He stated that he did not remember any other GPWS warnings during the
approach. The first officer indicated in a postaccident interview that he heard both the “sink rate”
and the “pull up” GPWS warnings but that he believed that the captain was correcting.
PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this
accident was the flight crew’s excessive airspeed and flightpath angle during the approach and
landing and its failure to abort the approach when stabilized approach criteria were not met.
Contributing to the accident was the controller’s positioning of the airplane in such a manner as
to leave no safe options for the flight crew other than a go-around maneuver.
