NTSB Factual Report

The Safety Board adopted the final report of this accident investigation, including the analysis and probable cause, on May 23, 2006. The Board's full report is available on: http://www.ntsb.gov/publictn/2006/AAB0605.pdf. The following is the FACTUAL portion of the report.

HISTORY OF FLIGHT

On October 24, 2004, about 0025 Pacific daylight time, [1] 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, [2] 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. [3]

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 [4] revealed that the airplane departed runway 8L at 0023 and climbed on a straight-out departure. The published departure procedures for IFR aircraft [5] departing from runway 8L included a climbing left turn to a heading of 280 degrees, 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 degrees, 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 [6] 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), [7] 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.

PERSONNEL INFORMATION

The director of operations (DO) for ATIJ provided personnel records, training records, drug test results, and duty and flight time records for the captain and the copilot. The information in this section was extracted from that data, Federal Aviation Administration (FAA) records, and pilot logbooks.

The Captain

The captain, age 56, held an airline transport pilot certificate with a rating for airplane multiengine land and type ratings for CL-604 (Challenger) airplanes, IA-Jet (Westwind) airplanes, and Learjet airplanes (the Learjet model was not specified). He also held a commercial pilot certificate with a rating for airplane single-engine land. The captain's most recent FAA first-class airman medical certificate was issued on October 8, 2003, with a limitation that he must possess lenses for near vision.

The captain completed ATIJ's initial general ground training and initial crewmember emergency training, which included a review of the company's previous accidents and incidents, on August 21, 2004. According to ATIJ's DO, the review included a controlled flight into terrain (CFIT) scenario.

From August 23 to 27, 2004, the captain completed a Learjet 35/36 Part 135 pilot recurrent training course. The course was held at FlightSafety International's (FSI) Tucson, Arizona, training facility, and the course included 12 hours of simulator training, 15 hours of ground training, and 4 hours of briefing/debriefing training. During one of the simulator sessions, CFIT was addressed as a special-emphasis area. A review of the captain's FSI training records revealed that he received positive comments from his instructor.

On August 21, 2004, the captain passed the knowledge items required by 14 CFR 135.293, "Initial and Recurrent Pilot Testing Requirements," paragraph (a), items 1 and 8. On August 27, 2004, while at FSI, the captain passed the knowledge tests required by 14 CFR 35.293, paragraph (a), items 2 and 3, and the checkride required by 14 CFR 135.297, "Pilot in Command: Instrument Proficiency Check Requirements." On September 10, 2004, the captain passed the flight check required by 14 CFR 135.299, "Pilot in Command: Line Checks: Routes and Airports," while flying the accident airplane.

An ATIJ pilot personal data form listed the captain's total flight time as 13,000 hours and his total instrument time as 900 hours. A review of the captain's logbook entries between February 1997 and February 2000 revealed that he logged a total of 525 hours of flight time in Learjet 35 airplanes and 639 hours of flight time in Learjet 25D airplanes.

A review of the duty time sheets provided by ATIJ revealed that the captain had accumulated a total of 70 hours duty time and 36 hours flight time during September 2004 and 67 hours duty time and 38 hours flight time during October 2004. All of the flight hours were accumulated in Learjet 35 airplanes.

According to his wife, the captain had flown to SDM at least once before; that flight was in January 2003.

The Copilot

The copilot, age 30, held a commercial pilot certificate and a flight instructor certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. His most recent FAA first-class airman medical certificate was issued on April 8, 2004, with the limitations that he must wear corrective lenses for distant vision and possess lenses for near vision.

The copilot completed ATIJ's initial general ground training and initial crewmember emergency training on August 21, 2004. As previously stated, the training included a review of the company's previous accidents and incidents, including a CFIT scenario.

From August 23 to 27, 2004, the copilot completed a Learjet 35/36 Part 135 pilot recurrent training course at FSI. As previously stated, during one of the simulator sessions, CFIT was addressed as a special-emphasis area. A review of the copilot's FSI training records revealed that he received positive comments from his instructor.

On April 16, 2004, the copilot passed the competency check and knowledge tests required by 14 CFR 135.293, paragraphs (a) and (b), while flying a Learjet 25. On August 21, 2004, the copilot passed an oral test, as outlined in paragraph (a), items 1 and 8. On August 27, 2004, he passed the tests outlined in paragraph (a), items 2 and 3, while in a Learjet 35A simulator.

An ATIJ pilot personal data form completed by the copilot indicated that he logged a total of 3,000 hours of flight time with 375 hours of instrument time. An MFAA pilot questionnaire indicated that, in 2004, the copilot accumulated about 100 flight hours in a Learjet 25.

A review of the copilot's duty time sheets revealed that he accumulated a total of 74 hours duty time and 29 hours flight time during September 2004 and 54 hours duty time and 32 hours flight time during October 2004. All of the flight hours were accumulated in Learjet 35 airplanes.

A review of the copilot's flight log revealed no record of previous flights into or out of SDM.

Flight Crew 72-Hour History

On October 21, 2004, the captain and the copilot worked a 10-hour duty day that included 7.4 hours flight time in the accident airplane. During a flight leg from Casper, Wyoming, to Battle Creek, Michigan, the airplane had a generator problem, and the captain and the copilot remained overnight in Michigan while the airplane underwent maintenance. On October 22, 2004, the captain and the copilot returned the airplane to its base at ABQ, and each pilot logged 3.3 hours of flight time during 4.3 hours of duty time, which ended at 1730.

After the captain completed his duty day, he spent the evening with his wife and went to bed about 2130. The next morning, which was the day of the first leg of the accident trip, the captain awoke about 0700. He and his wife ate breakfast, read the newspaper, and went shopping. While they were shopping, the captain received a call from MFAA regarding the accident trip. The captain left for ABQ about 1330.

After the copilot completed his duty day on October 22, 2004, he met with his mother-in-law, spent the rest of the evening with his wife relaxing, and went to bed about 2130. The next morning, which was the day of the first leg of the accident trip, the copilot awoke about 0830, helped his in-laws move some furniture, and spent the rest of the morning and early afternoon shopping. According to the copilot's wife, he received the call for the accident trip about 1410. She stated that he drove her home and then left for ABQ.

A review of dispatch logs revealed that, during the 24 hours before the accident, the captain and the copilot each accumulated about 6.5 hours of flight time and about 11 hours of duty time. Title 14 CFR 135.267(b), "Flight Time Limitations and Rest Requirements: Unscheduled One- and Two-Pilot Crews," was applicable to the trip legs before the accident flight that were subject to Part 135 rules. The regulation states the following: " Except as provided in paragraph (c) of this section, during any 24 consecutive hours the total flight time of the assigned flight when added to any other commercial flying by that flight crewmember may not exceed…10 hours for a flight crew consisting of two pilots."

Paragraph (c) of the regulation states that the flight crewmember's flight time may exceed the flight time limit included in paragraph (b) if the following were to occur: "The assigned flight time occurs during a regularly assigned duty period of no more than 14 hours, and (1) if this duty period is immediately preceded by and followed by a required rest period of at least 10 consecutive hours of rest; (2) if flight time is assigned during this period, that total flight time when added to any other commercial flying by the flight crewmember may not exceed…10 hours for a flight crew consisting of two pilots; and (3) if the combined duty and rest periods equal 24 hours."

AIRPLANE INFORMATION

The airplane was powered by two Honeywell TFE731-2-2B turbine engines. The airplane underwent a medical conversion and was configured to accommodate two flight crewmembers, three medical crewmembers, one medical patient, and one additional passenger. A review

NTSB Probable Cause

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.