N880Z

HISTORY OF FLIGHTOn December 27, 2021, about 1914 Pacific standard time, a Gates Learjet Corporation 35A, N880Z, was destroyed when it was involved in an accident near El Cajon, California. The 2 pilots and 2 flight nurses were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 repositioning flight.

Earlier in the day, the flight crew had flown from Lake Havasu City Airport (HII), Lake Havasu, Arizona, to John Wayne/Orange County Airport (SNA), Santa Ana, California, for a patient transfer. They departed SNA about 1856 to reposition to their home base at Gillespie Field (SEE), El Cajon, California.

Review of communication recordings revealed that at 1908:23, the pilot contacted the SEE Air Traffic Control Tower (ATCT) and reported to the controller they were on the GPS approach to runway 17. The controller issued the current wind and cleared the pilot to land on runway 17. At 1912:03, the pilot reported the airport in sight and requested to squawk VFR. The controller did not acknowledge the request to squawk VFR; however, he reissued the landing clearance for runway 17.

At 1912:13, the pilot requested to land on runway 27. The controller asked the pilot if they wanted to cancel their IFR flight plan, to which the pilot replied, “yes sir.” The controller acknowledged that the IFR cancellation was received and instructed the pilot to overfly the field and enter left traffic for runway 27R and cleared them to land on runway 27R. At 1912:30, the pilot requested that the runway lights for runway 27R be increased; however, the controller informed them that the lights were already at 100 percent. No further radio communication between the pilots and the tower controller was heard.

Review of the CVR recording revealed that, following the approach clearance, the flight crew discussed their intent to cancel the approach and circle to land on runway 27R. Additionally, the flight crew asked one another if they could see the runway. Once the flight crew established visual contact with the runway, they requested to squawk VFR. The copilot, who was the pilot flying, asked the captain, “where is the runway” just before the controller noted that the lights were at 100 percent. About 3 seconds later, the copilot said “perfect, I got it now.” The captain asked the copilot two more times if he had the airport in sight; the copilot confirmed that he did and commented, “we’re gonna head right down the runway” and “then we’ll make a left.” About 12 seconds later, the captain stated “don’t go any lower” as the copilot asked him to call the left turn. About 13 seconds later, the captain said, “make your left turn,” followed by him telling the copilot to straighten out 16 seconds later. The copilot asked the captain to tell him when to make a left turn, and 10 seconds later the captain told him to make the turn. The copilot stated, “I see that little mountain, okay” followed by both the captain and co-pilot saying “woah woah woah, speed, speed” 3 seconds later. During the following 5 seconds, the captain and copilot both stated, “go around the mountain,” followed by the captain saying, “this is dicey” and the copilot responding, “yeah it’s very dicey.” Shortly after, the captain told the copilot “here” let me take it on this turn” followed by the copilot saying, “yes, you fly.” The captain asked the copilot to watch his speed and the co-pilot agreed. About 1 second later the copilot stated, “speed speed speed, more more, more more, faster, faster.” Soon after, the CVR indicated that the airplane impacted the terrain.

ADS-B data showed that after departure from SNA, the flight made a left turn out over the waters of the Pacific Ocean and flew generally south-southeast along the coast and ascended to a cruise altitude of about 11,000 ft msl. After the flight passed Carlsbad, California, the airplane turned left and began to descend toward SEE. As shown in Figure 1, ADS-B data showed that the airplane was at 1,000 ft msl at the time flight crew reported the runway in sight. Additionally, as the airplane was abeam the HIRAK missed approach point, it was at an altitude of 700 ft msl. The data showed that the airplane overflew SEE at an altitude of about 775 ft msl (407 ft agl) and entered a left downwind for runway 27R. While on the downwind leg, the airplane descended to an altitude of 700 ft msl, then ascended to an altitude of 950 ft msl while on the base leg. The last recorded ADS-B target was at 1914:09, at an altitude of 875 ft msl, about 100 ft southeast of the accident site.

Figure 1: Recorded ADS-B data with ATC communication annotations.

Numerous witnesses located in the vicinity of the accident site reported observing various segments of the accident sequence. One witness stated that the airplane went over their residence extremely low when it made a “very hard steep turn to the left” and that the wing was “basically pointing straight down to the ground” before “it crashed.” PERSONNEL INFORMATIONCaptain

Aeromedavac hired the captain in June 2019, and had upgraded him to captain on July 16, 2021. The captain’s most recent proficiency check was completed on October 11, 2021.

Copilot

Aeromedavac hired the copilot in May 2019. The copilot’s initial training was completed on May 13, 2019, with recurrent training completed on May 6, 2020, and May 16, 2021. AIRCRAFT INFORMATIONThe airplane was manufactured in 1985 and was configured for air medical transport. The airplane was equipped with various stall warning devices, angle of attack indicators, and a control stick shaker. The airplane had L and R STALL WARNING switches, located on the center switch panel, that provided power to the corresponding stall warning system. Each switch had two positions: On and Off. The L STALL WARNING switch also provided power for the stick pusher. According to the Flight Safety International Lear Jet 35/36 Pilot Training Manual, the stick shaker motors were attached to the front side of each control column. Actuation of the shaker caused a high-frequency vibration in the control columns.

Additionally, the airplane had two red L STALL and R STALL warning lights, located in the glareshield annunciator panel, that were installed to indicate an impending stall or a system malfunction. During flight operations, the lights would illuminate and flash when the stick shaker was activated. The lights were pulsed at the same frequency and duration as the shakers; therefore, the flash duration would increase as the angle of attack increased from initial shaker activation. At, or just before, pusher actuation, the flash duration was sufficient to cause the lights to appear steady. Steady illumination of the lights at any time other than pusher actuation indicated a computer loss or an internal malfunction. The lights would illuminate whenever the STALL WARNING switches were off, and the battery (BAT) switches were on.

The wings-level stall speed published in the LearJet 35A Federal Aviation Administration (FAA)-Approved Airplane Flight Manual (AFM) at the landing flap setting and a gross weight of 14,350 lb is approximately 96 kts. The stall speed increases to 119 kts in a level 50° banked turn and to 134 kts in a 60° banked turn. METEOROLOGICAL INFORMATIONThe most recent reported observation at SEE was issued at 1855, about 20 minutes before the accident, which reported variable wind at 5 knots, visibility 3 statute miles, mist, a broken cloud layer at 2,000 ft, overcast cloud layer at 2,600 ft, a temperature of 10°C, a dew point of 8°C, and an altimeter setting of 29.98 inches of mercury.

One-minute weather data was downloaded from the AWOS. The data showed that at 1901, visibility was 2.5 miles, broken cloud layer at 1,400 ft, broken cloud layer at 2,100 ft, broken cloud layer at 2,800 ft. The data showed that at 1908, when the flight crew contacted SEE ATCT, weather conditions included visibility 2 miles, few clouds at 900 ft, broken cloud layer at 1,500 ft, broken cloud layer at 1,800 ft. Recorded weather showed that at 1912, when the flight crew reported the airport in sight, weather conditions were visibility 2.5 miles, few clouds at 900 ft, broken cloud layer at 1,600 ft, and an overcast cloud layer at 2,800 ft. At the time of the accident, weather conditions were visibility 2.5 miles, few clouds at 1,000 ft, a broken cloud layer at 1,600 ft, and an overcast cloud layer at 2,800 ft.

According to FAA data, on the accident day and relative to the accident location, sunset occurred at 1649 and civil twilight ended at 1716.

Airmen’s Meteorological Information (AIRMET) advisories for IFR conditions, mountain obscuration, moderate turbulence below FL180, low-level wind shear (LLWS) and moderate icing between the freezing level and 17,000 ft were active for the accident location at the accident time. The same AIRMETs for moderate turbulence below FL180 and LLWS were reissued at 1913.

A pilot report obtained at 1920, showed that the pilot(s) of a Citation 525 reported LLWS while on a 2-mile final to Mongomery Field Airport, San Diego, California, about 8 miles west of SEE.

14 CFR 91.155 outlines weather minimums for Visual Flight Rules. Class D and Class E airspace below 10,000 ft require visibility of 3 statute miles, 500 ft below clouds, 1,000 ft above clouds, and 2,000 ft horizontal distance from clouds. AIRPORT INFORMATIONThe airplane was manufactured in 1985 and was configured for air medical transport. The airplane was equipped with various stall warning devices, angle of attack indicators, and a control stick shaker. The airplane had L and R STALL WARNING switches, located on the center switch panel, that provided power to the corresponding stall warning system. Each switch had two positions: On and Off. The L STALL WARNING switch also provided power for the stick pusher. According to the Flight Safety International Lear Jet 35/36 Pilot Training Manual, the stick shaker motors ...