Safety Pilot Landmark Accidents: An Inconvenient Departure

You can't move a mountain

January 1, 2007

We've always been told that the shortest distance between two points is a straight line, but when terrain intervenes, the long way around may be the only way around. Although this Landmark Accident happened to a professional jet crew, the lessons apply to all who fly at night, whether VFR or IFR.

Unfortunately the accident scenario is familiar. Attempting to move mountains with aircraft has never been a successful strategy.

A medical charter company dispatched a Learjet 35 from Albuquerque at 3:20 p.m. (all times are Pacific Daylight Time) on October 23, 2004, to pick up a medical crewmember in El Paso, Texas, and then fly to Mexico to retrieve a patient. The Lear left El Paso at 4:25 p.m. for Manzanillo, Mexico, arriving two hours later, where it picked up the medical patient and one accompanying passenger. The airplane then departed Manzanillo at 8:40 p.m. and flew to San Diego's Brown Field Municipal Airport where the aircraft landed at 11:25 and dropped off the patient.

One of the pilots called the San Diego Flight Service Station (FSS) at 12:02 a.m. to file an IFR flight plan to Albuquerque. The planned 12:20 departure was from San Diego direct to Palm Springs, California, and then direct to Albuquerque at Flight Level 370 (37,000 feet). The estimated time en route was 1 hour, 15 minutes with three hours of fuel on board.

No one's home

The contract tower at Brown Field closed at 10 p.m. so the normal delivery of IFR clearances via radio was not available. It's a hassle when you can't speak directly to ATC, but in less-traveled places or on the back side of the clock, the routine is often to call either FSS or clearance delivery on the phone. The Lear's cockpit voice recorder (CVR) confirmed that the crew heard the automatic terminal information service (ATIS) recording but listened only to the remarks portion of the recording and not the weather information. The co-pilot then attempted to contact "Brown Field Municipal Clearance" on the ground control frequency but received no response. The captain suggested trying the Tijuana Tower, which was about 10 miles away. The co-pilot volunteered that they could pick up the flight's clearance in the air but then stated, "I don't want to do it, but...."

The co-pilot then tried the San Diego FSS via the remote communications outlet frequency but received no reply. He called Tijuana Tower but there was no answer. Another call was made to the San Diego FSS using a different frequency, but no one responded. After the co-pilot's fourth failed attempt to pick up an IFR clearance, the captain said, "All right, let's just do VFR [visual flight rules]." Despite having a cell and a satellite telephone on board, neither pilot thought to telephone FSS for an IFR clearance and a void time. A single phone call would have avoided the tragedy that was about to unfold.


In discussing the departure, the captain wanted to use Runway 8L to avoid flying over the city with a heading toward Albuquerque, and the co-pilot agreed. Launching on this runway also pointed the aircraft directly at the mountainous terrain east and northeast of the airport, but that wasn't discussed.

The crew then ran the before-takeoff checklist, and when the co-pilot asked for a briefing, the captain responded, "Uh, let's see.... Will be standard call-outs 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 250 knots, and I'll do the best I can to get somebody's attention." This was followed by the sound of takeoff power being set on the engines.

According to the radar track, the Lear departed Runway 8L at 12:23 a.m. and climbed straight out. However, the published IFR departure procedure from Runway 8L required a climbing left turn to a heading of 280 degrees, which was a complete course reversal to avoid the mountains east and northeast of Brown Field and opposite the desired direction of flight.

No help from the ground

The captain contacted the Southern California Terminal Radar Approach Control (SOCAL Tracon) controller after takeoff to pick up the flight's IFR clearance. The controller provided a transponder code and asked for an "ident." The radar track showed that the Lear climbed to 2,300 feet msl, leveled out, and continued on runway heading.

At 12:24:55 a.m., the controller advised radar contact, and instructed the flight to turn left to 020 degrees, maintain VFR, and expect an IFR clearance above 5,000 feet msl. Nothing was said about terrain. The captain acknowledged and there was no further radio communication. At the time the controller issued the instructions, the flight was 3.5 nautical miles west of the mountains, and the new heading, issued by the controller, still continued toward the mountains.

The last radar altitude return, at 12:25:03 a.m., showed the Lear about six nm east of Brown Field at 2,300 feet msl. The controller received a minimum safe altitude warning (MSAW — the ATC's computer system provides alerts when a tracked Mode C-equipped aircraft is below, or is predicted by the computer to be below, a predetermined minimum safe altitude) with both aural and visual alerts on the controller's display during the flight's last two Mode C radar returns, at 12:24:59 and 12:25:03. Unfortunately, according to the controller, it went unnoticed as he was on the land line discussing the flight and advising Tijuana that it would be close to Mexican airspace. At 12:25:56 and shortly thereafter, the controller attempted several radio contacts but received no reply. After several unsuccessful attempts, a search-and-rescue operation was initiated.

The Lear slammed into mountainous terrain about eight nm east of Brown Field at 2,256 feet msl. The San Diego Police Department's helicopter arrived at the site about 20 minutes after the accident and reported a broken-to-overcast layer of clouds that was about 75 to 100 feet above the accident site elevation.

Personnel information

The 56-year-old captain held an airline transport pilot certificate with multiple jet type ratings. His total flight time was in excess of 13,000 hours with more than 1,150 in Learjets. He had completed recurrent simulator and ground training less than two months before the accident, including a special controlled flight into terrain (CFIT) scenario. The captain had flown 38 hours in the Lear 35 in the three weeks prior to the accident and had been into Brown Field at least once before.

The 30-year-old co-pilot held a commercial pilot certificate and a flight instructor certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He had attended the same simulator recurrent training course as the captain, and both crewmembers had completed the charter company's special-emphasis course on CFIT, which should have addressed departure procedures. The co-pilot had a total of 3,000 hours of flight time with about 100 flight hours in a Learjet 25, but was new to the Lear 35.

His duty time sheets revealed he had logged 32 hours in October in the Lear 35.

The NTSB looked at the three days prior to the flight to determine what effects the crew's activity might have had on the accident flight. On October 21 — two days before the accident — both pilots had worked a 10-hour duty day that included 7.4 hours' flight time in the accident airplane. There was a generator problem and the crewmembers remained over-night in Michigan while the generator was fixed. On October 22, they flew back to Albuquerque, logging 3.3 hours of flight time, which ended at 5:30 p.m.

The captain went to bed about 9:30 p.m. The next day, which was the day of the first leg of the accident trip, he awoke at 7 a.m. He was called for duty around midday and left for the airport about 1:30 p.m. The co-pilot also went to bed about 9:30 p.m., and he awoke the next morning about 8:30, helped his in-laws move some furniture, and spent the rest of the morning and early afternoon shopping. He received the call for the accident trip about 2:10 p.m. and left for the airport.

The air traffic controller who worked the flight started with the FAA on December 4, 1987, and worked at the Southern California Tracon in 1994 and 1995. He returned to the tracon in February 1998 and achieved area certification on December 8, 1999. The controller had previously worked at the Brown Tower and so was well familiar with the area.

On October 23, 2004, the controller worked from 6:30 a.m. to 2:30 p.m. He returned for duty at 11 p.m. for the midnight shift that ran from midnight to 8 a.m. on October 24, 2004. The controller did not sleep before reporting for the midnight shift but reported that he was not tired when he handled the accident flight. (A similar work schedule of back-to-back shifts was followed by the controller who was working the Comair flight that crashed in Lexington, Kentucky, last fall; see " Safety Pilot: Wrong Runway," November 2006 Pilot.)


In looking at the duty times of both pilots and the controller, although they technically met the letter of the law, we see that everybody had been awake for an extended period. The CVR recorded that the co-pilot yawned five times within six minutes during the departure discussion. The captain had been awake for 17 hours and the controller for at least two hours longer than that. This is not a recipe for success. The checks and balances that should be in place break down rapidly when all the players are operating contrary to circadian rhythm. Pilot, co-pilot, and controller likely all had some elements of fatigue based on duty time alone. No one was mentally sharp enough to spot the links in the accident chain before it was too late.

Who's responsible?

Lest you think that ATC will always keep you out of the high ground, read the following carefully. The controller acknowledged that he was aware of the mountains east of Brown Field. When asked why he didn't warn the crew of the terrain, the controller said that it was the pilot's responsibility to avoid terrain when operating under VFR. The controller said that he did not distinguish between day or night operations when providing VFR advisories to pilots. The operational conditions in mountainous terrain are like day and night, if you'll pardon the pun, and the comment provides insight into the narrow view this controller took of his responsibilities. The controller was aware of the cloud ceiling at 2,100 feet agl, and he expected the pilots to maintain VFR and to advise him if they were unable to do so.

The FAA's guidance to controllers is a bit more expansive:

"Treat an aircraft planning VFR for the initial part of flight and IFR for the latter part as a VFR departure. Issue a clearance to this aircraft when it requests IFR clearance approaching the fix where it proposes to start IFR operations. When a VFR aircraft, operating below the minimum altitude for IFR operations, requests an IFR clearance and you are aware that the pilot is unable to climb in VFR conditions to the minimum IFR altitude: Before issuing a clearance, ask if the pilot is able to maintain terrain and obstruction clearance during a climb to the minimum IFR altitude. Note: Pilots of pop-up aircraft are responsible for terrain and obstacle clearance until reaching the minimum IFR altitude or the minimum en route altitude. Pilot compliance with an approved FAA procedure or an ATC instruction transfers that responsibility to the FAA; therefore, do not assign (or imply) specific course guidance that will (or could) be in effect below the MIA or MEA. [In this case, as soon as the controller issued the heading of 020 degrees, it became his responsibility to keep the Lear away from the mountains.] If unable to maintain terrain and obstruction separation, instruct the pilot to maintain VFR and to state intentions."

According to FAA Order 7110.65P, chapter 2-1-6, "Safety Alert," the procedures for controllers include the following: "Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude, which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft. The issuance of a safety alert is a first priority...once the controller observes and recognizes a situation of unsafe aircraft proximity to terrain, obstacles, or other aircraft. Conditions, such as workload, traffic volume, the quality/limitations of the radar system, and the available lead time to react, are factors in determining whether it is reasonable for the controller to observe and recognize such situations."

NTSB determination

When the controller was asked why he did not advise the flight crew of the MSAW alerts, he claimed not to have heard or observed the MSAW alerts because he was talking with Tijuana when the alerts began. A review of radar and communications data, however, did not support that statement. The MSAW alerts began 34 seconds before the call to Tijuana, and radar contact with the flight had been lost for 15 seconds before the controller began coordinating the accident airplane's position with the other controller.

Moreover, the controller was not handling any other aircraft during the accident flight; thus, workload demands should not have been a distraction. This, according to the NTSB, "suggests that the controller may have been aware of the MSAW alerts but disregarded them because of his belief that it was not his responsibility to provide alerts to flight crews operating under VFR. According to FAA Order 7110.65P, chapter 2-1-6, the issuance of a safety alert is a controller's first priority regardless of whether the flight is operating under VFR or IFR."

The NTSB determined that the probable causes of this accident were "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."

Although it's nice to think that ATC will bail you out in the case of brain lock or misjudgment, remember that the pilot in command retains the final authority as to the safety of the flight and is always the first on the scene of the accident. The pilots clearly dropped the ball, no question. The controller attempted to dodge his responsibility by claiming he expected the pilots to maintain VFR and not hit the mountain, despite his knowing that there was high terrain directly in front of them and with his equipment warning of an impending impact.

ATC always has the benefit of local knowledge that pilots often do not, as we are frequently transient to an area. Two NTSB members appended a statement of concern to the report. They felt that it did not specifically address two obvious weaknesses, controller fatigue and failure to warn.

"The controller identified the transponder code of the aircraft and, more important, issued heading and expected IFR clearance information. Yet, this controller failed to issue a terrain safety warning despite knowledge of the surrounding terrain, awareness of the cloud cover, and two distinct warnings generated by the minimum safe altitude warning (MSAW) system.... The Tracon staff generally seems unaware of the serious safety responsibilities they have for flight crews operating under night visual flight rules, particularly in circumstances involving hazardous terrain."

Although the FAA discusses who should be responsible for what, pilots should operate from the viewpoint that the safety net currently has some large holes.

Bruce Landsberg is executive director of the AOPA Air Safety Foundation.

From the AOPA Air Safety Foundation: At night or in marginal conditions follow IFR departure procedures. These can be found in IFR chart books or by calling FSS. Not sure you can maintain VFR to avoid the terrain? Then obtain an IFR clearance before entering such conditions. Do not depend on ATC to keep you out of the rough. The ASF online course, Mountain Flying, teaches pilots about the challenges of high-density-altitude operations, flight planning and performance considerations, mountain weather, and more.