Lockheed C-130 Hercules

USAF and US authorities concluded that no single factor or individual act or omission was the cause of the collision. Investigations concluded that it was the consequence of a tragic confluence of events, missed opportunities, and procedure/policy issues in an airspace where most aircraft fly under a "see-and-avoid" regime. A contributory factor was that FACSFAC San Diego did not provide operational priority to the crew of the Lockheed Hercules.

The Board President could not find clear and convincing evidence to determine the exact cause of the engine power loss. He did find evidence to conclude that several factors combined to significantly contribute to the Mishap Airplane (MA) landing partially gear down. Specifically, a defensive system alert, the aircraft's low altitude and airspeed at the time of the malfunction, and the decision to respond to the alert at low altitude and airspeed combined to result in the MA landing partially gear down. All MA systems and performance were normal prior to the defensive system alert. An undetermined malfunction occurred during the defensive reaction that caused three of the MA's four engines to stabilize at an RPM (60%) which was not sufficient to maintain flight and the low altitude and airspeed at the time of the malfunction limited the time available for situation analysis and recovery. The Mishap Crew (MC) had never been exposed to a loss of three or four engines on takeoff in the C-130H2 simulator which resulted in an emergency situation the MC had not seen before at a low altitude and airspeed. Checklist actions taken by the MC did not recover the engines and the Mishap Pilot (MP) appropriately performed a limited power, controlled descent, and forced landing resulting in only minor injuries.