Aircraft Accident Brief - Controlled Flight Into Terrain Learjet 35A, N30DK

San Diego, California
October 24, 2004

NTSB Number: AAB-06-05
Adopted May 23, 2006
PDF

History of Flight

On October 24, 2004, about 0025 Pacific daylight time, a Learjet 35A, N30DK, registered to and operated by Med Flight Air Ambulance, Inc. (MFAA), crashed into mountainous terrain shortly after takeoff from Brown Field Municipal Airport (SDM), near San Diego, California. The captain, the copilot, and the three medical crewmembers were killed, and the airplane was destroyed. The repositioning flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 with an instrument flight rules (IFR) flight plan filed. Night visual meteorological conditions prevailed.

The accident flight was the fourth and final leg of a trip that originated the previous day. ATI Jet, Inc. (ATIJ), dispatched the airplane, the two flight crewmembers, and two of the medical crewmembers from Albuquerque International Sunport (ABQ), Albuquerque, New Mexico, about 1500 on October 23, 2004, for a repositioning flight to pick up another medical crewmember and a transport flight to pick up a medical patient in Mexico. According to MFAA personnel, repositioning flights were conducted under 14 CFR Part 91 rules, and medical patient transport flights were operated under Part 135.

On the flight's first leg, the airplane departed ABQ about 1520 and landed at El Paso International Airport (ELP), El Paso, Texas, about 1555 to pick up the third medical crewmember. On the flight's second leg, the airplane departed ELP about 1625 for Playa De Oro International Airport (MMZO), Manzanillo, Mexico, where it landed about 1825 to pick up the medical patient and one accompanying passenger. On the flight's third leg, the airplane departed MMZO about 2040 and flew to SDM, where it landed about 2324 to drop off the medical patient and the passenger. The airplane was then met by U.S. Customs Service personnel and was on the ground for about 1 hour before it departed on the accident flight to return the airplane to its base at ABQ.

A review of records from the San Diego Flight Service Station (FSS) revealed that one of the flight crewmembers filed the IFR flight plan to ABQ at 0002 on October 24, 2004. The filed route of flight included an estimated 0020 departure from SDM with a cruise altitude of flight level 370 (37,000 feet pressure altitude) direct to Palm Springs, California, and then direct to ABQ. The flight plan included an estimated time en route of 1 hour 15 minutes with 3 hours of fuel on board the airplane. The flight crewmember did not request any weather information or an IFR clearance and clearance void time.

The cockpit voice recorder (CVR) recording revealed that the captain and the copilot listened to the SDM automatic terminal information service (ATIS) recording; however, they listened only to the remarks portion of the recording and did not listen to the weather information. The copilot then attempted to contact "Brown Field Municipal clearance" on the radio frequency, but he received no response. The captain suggested that the copilot could try contacting the Tijuana tower. The copilot stated he could pick up the flight's clearance in the air but then stated, "I don't want to do it but..."

The copilot then tried to contact the San Diego FSS via the remote communications outlet frequency but received no reply. He next tried to contact the Tijuana tower but again received no reply. Afterward, the copilot tried to contact the San Diego FSS utilizing a different radio frequency but still received no reply. After the copilot's fourth failed attempt to obtain the IFR clearance using the radio, the captain said, "all right, let's just do VFR [visual flight rules]."

According to the operator, the flight crew had a cellular telephone and a satellite telephone on board the airplane. The CVR recording revealed no attempt by either crewmember to telephone the FSS for an IFR clearance and clearance void time.

The captain and the copilot discussed the departure. The captain stated that he wanted to depart from runway 8 to avoid flying over the city of San Diego. He also stated that a runway 8 departure would place the flight on a heading straight toward ABQ, and the copilot agreed with this statement. Neither the captain nor the copilot mentioned the mountainous terrain to the east and northeast as a consideration in deciding which runway to use for departure. The CVR recording revealed that the copilot yawned five times within 6 minutes during the departure discussion.

According to the CVR recording, the captain and the copilot performed the checklist items and set the altimeters to 29.93 inches of mercury (Hg). The copilot then asked for a briefing, to which the captain responded, "uh, let's see. will be standard callouts tonight and, if you can't punch up through a nice hole then just uh, you know, stay at a reasonably safe altitude and uh, underneath two hundred and fifty knots, and I'll do the best I can to, get somebody's attention." This statement was followed by the sound of takeoff power being set on the engines.

A review of radar data revealed that the airplane departed runway 8L at 0023 and climbed on a straight-out departure. The published departure procedures for IFR aircraft departing from runway 8L included a climbing left turn to a heading of 280°, which was a nearly complete course reversal to avoid the mountains east and northeast of SDM.

According to air traffic control (ATC) transcripts, the captain contacted the Southern California Terminal Radar Approach Control (SCT TRACON) controller after takeoff to pick up the flight's IFR clearance. The controller told the flight crew to set the transponder to code 7372 and "ident." A review of radar data revealed that the airplane climbed to about 2,300 feet mean sea level (msl) and leveled out, and its flight track remained approximately straight out from the departure runway.

At 0024:55, the controller stated the flight was radar identified, and he instructed the flight crew to turn to a heading of 020°, maintain VFR, and expect an IFR clearance above 5,000 feet msl. The captain acknowledged the heading instructions, and no further radio communication was received from the flight. A review of radar data revealed that, at the time the controller issued the instructions, the flight was about 3.5 nautical miles (nm) west of the mountains, and the heading issued by the controller resulted in a flight track that continued toward the mountains.

The last mode C radar return from the flight at 0025:03 depicted the airplane about 6 nm east of SDM at an altitude of 2,300 feet msl. A review of the controller's display data recording revealed the controller's computer system issued a minimum safe altitude warning (MSAW), which consisted of an aural alert and a visual alert on the controller's display, during the flight's last two mode C radar returns at 0024:59 and 0025:03. At 0025:56, the controller attempted to make radio contact with the flight but received no reply. After the controller's subsequent attempts to contact the flight crew were unsuccessful, a search and rescue operation was initiated.

The airplane wreckage was located about 8 nm east of SDM in a mountainous area southeast of Otay Mountain's highest peak. The initial impact point was at an elevation of 2,256 feet msl. The San Diego Police Department's Air Support Unit, which arrived at the site by helicopter about 20 minutes after the accident, used night vision goggles and infrared imaging to locate the wreckage. The Air Support Unit responders reported that they observed a broken-to-overcast layer of clouds near Otay Mountain while flying to the accident site and that the elevation of the main impact crater at the site was about 75 to 100 feet below the observed cloud layer.

Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flight crew to maintain terrain clearance during a VFR departure, which resulted in controlled flight into terrain and the air traffic controller's issuance of a clearance that transferred the responsibility for terrain clearance from the flight crew to the controller, failure to provide terrain clearance instructions to the flight crew, and failure to advise the flight crew of the MSAW alerts. Contributing to the accident was the pilots' fatigue, which likely contributed to their degraded decision-making.