San Diego-Brown Field

The Cessna 172 (N1285U) was conducting touch-and-go landings at Brown Field Municipal Airport (SDM), San Diego, California, and the experimental North American Rockwell NA265-60SC Sabreliner (N442RM, call sign Eagle1) was returning to SDM from a mission flight. SDM has two parallel runways, 8R/26L and 8L/26R; it is common in west operations for controllers to use a right traffic pattern for both runways 26R and 26L due to the proximity of Tijuana Airport, Tijuana, Mexico, to the south of SDM. On the morning of the accident, the air traffic control tower (ATCT) at SDM had both control positions (local and ground control) in the tower combined at the local control position, which was staffed by a local controller (LC)/controller-in-charge, who was conducting on-the-job training with a developmental controller (LC trainee). The LC trainee was transmitting control instructions for all operations; however, the LC was monitoring the LC trainee's actions and was responsible for all activity at that position. About 13 minutes before the accident, the N1285U pilot contacted the ATCT and requested touch-andgo landings in the visual flight rules (VFR) traffic pattern. About that time, another Cessna 172 (N6ZP) and a helicopter (N8360R) were conducting operations in the VFR traffic pattern, and a Cessna 206 Stationair (N5058U) was inbound for landing. Over the next 5 minutes, traffic increased, with two additional aircraft inbound for landing. (Figure 1 in the factual report for this accident shows the aircraft in the SDM traffic pattern about 8 minutes before the accident.) The LC trainee cleared the N1285U pilot for a touch-and-go on runway 26R; the pilot acknowledged the clearance and then advised the LC trainee that he was going to go around. The LC trainee advised the N1285U pilot to expect runway 26L on the next approach. At that time, three aircraft were using runway 26R (Global Express [N18WZ] was inbound for landing, N6ZP was on a right base for a touch-and-go, and a Cessna Citation [XALVV] was on short final) and three aircraft were using runway 26L (N1285U was turning right downwind for the touch-and-go, a Skybolt [N81962] was on a left downwind for landing, and N8360R was conducting a touch-and-go landing). After N1285U completed the touch-andgo on runway 26L, the pilot entered a right downwind for runway 26R. Meanwhile, Eagle1 was 9 miles west of the airport and requested a full-stop landing; the LC trainee instructed the Eagle1 flight crew to enter a right downwind for runway 26R at or above an altitude of 2,000 ft mean sea level. At this time, about 3 minutes before the accident, the qualified LC terminated the LC trainee's training and took over control of radio communications. From this time until the collision occurred, the LC was controlling nine aircraft. (Figure 2 and Figure 4 in the factual report for this accident show the total number of aircraft under ATCT control shortly before the accident.) During the next 2 minutes, the LC made several errors. For example, after N6ZP completed a touch-andgo on runway 26R, the pilot requested a right downwind departure from the area, which the LC initially failed to acknowledge. The LC also instructed the N5058U pilot, who had been holding short of runway 26L, that he was cleared for takeoff from runway 26R. Both errors were corrected. In addition, the LC instructed the helicopter pilot to "listen up. turn crosswind" before correcting the instruction 4 seconds later to "turn base." (Figure 2 in the factual report for this accident shows the aircraft in the traffic pattern about 2 minutes before the accident.) About 1 minute before the collision, the Eagle1 flight crew reported on downwind midfield and stated that they had traffic to the left and right in sight. At that time, N1285U was to Eagle1's right, between Eagle1 and the tower, and established on a right downwind about 500 ft below Eagle1's position. N6ZP was about 1 mile forward and to the left of Eagle1, heading northeast and departing the area. Mistakenly identifying the Cessna to the right of Eagle1 as N6ZP, the LC instructed the N6ZP pilot to make a right 360° turn to rejoin the downwind when, in fact, N1285U was the airplane to the right of Eagle1. (The LC stated in a postaccident interview that he thought the turn would resolve the conflict with Eagle1 and would help the Cessna avoid Eagle1's wake turbulence.) The N6ZP pilot acknowledged the LC's instruction and began turning; N1285U continued its approach to runway 26R. However, the LC never visually confirmed that the Cessna to Eagle1's right (N1285U) was making the 360° turn. Ten seconds later, the LC instructed the Eagle1 flight crew to turn base and land on runway 26R, which put the accident airplanes on a collision course. The LC looked to ensure that Eagle1 was turning as instructed and noticed that the Cessna on the right downwind (which he still mistakenly identified as N6ZP) had not begun the 360° turn that he had issued. The LC called the N6ZP pilot, and the pilot responded that he was turning. In the first communication between the LC and the N1285U pilot (and the first between the controllers in the ATCT and that airplane's pilot in almost 6 minutes), the LC transmitted the call sign of N1285U, which the pilot acknowledged. N1285U and Eagle1 collided as the LC tried to verify N1285U's position. A postaccident examination of both airplanes did not reveal any mechanical anomalies that would have prevented the airplanes from maneuvering to avoid an impact.

On October 24, 2004, about 0025 Pacific daylight time, a Learjet 35A twin-turbofan airplane, N30DK, registered to and operated by Med Flight Air Ambulance, Inc. (MFAA), collided 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 received fatal injuries, 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 flight, which was the fourth and final leg of a trip that originated the previous day, departed SDM at 0023.

The airplane took off from the airport on a left downwind departure and after reaching an altitude of approximately 300 feet, banked steeply and dove into the ground. Witness statements indicated that the takeoff ground roll extended to midfield of the runway, a distance of 4,850 feet before the airplane lifted off. According to the Airplane Flight Manual performance charts, the normal ground roll should have been about 2,100 feet. While turning crosswind, the airplane steepened its bank and continued toward the downwind. As the angle of bank approached 90 degrees, the nose dropped and the airplane descended to impact with trees and the ground. Several trees were struck before the airplane came to rest on the underlying terrain in the backyard of a residence. The airplane was thermally destroyed in the impact sequence and post crash fire. Calculations of the airplane weight and balance data put it at least 251 pounds over maximum allowable gross takeoff weight. Remaining wreckage not consumed in the ground fire was examined and the engine was sent to the manufacturer for inspection. No discrepancies were found. Cockpit instrumentation and all autopilot components were thermally destroyed. Flaps and landing gear were found in the retracted position and the elevator trim surface was slightly nose up from the takeoff setting. The autopilot had a reported history of malfunction and the electric elevator trim system was scheduled for repair a week before the accident, but the owner took the airplane prior to the work being performed. The airplane had been modified with the addition of several Supplemental Type Certificates, one of which was a wing spoiler system. The controls and
many of the actuating linkages for the spoiler system were destroyed in the fire.

The aircraft concluded an aerial survey and landed at Brown Field to clear U.S. Customs. On restart, as the left engine began running, a witness noticed two short, yellow flame bursts exit the exhaust. During taxi, the witness heard a popping sound coming from the aircraft. As power was applied to cross runway 26L, the sound went away. The aircraft stopped for a few seconds prior to pulling onto the runway; the witness did not observe or hear a run-up. Witnesses reported hearing a series of popping sounds similar to automatic gunfire and observed the aircraft between 600 and 1,000 feet above the ground with wings level and the landing gear up. The aircraft was observed to make an abrupt, 45-degree banked, left turn as the nose dipped down. Witnesses reported the nose of the aircraft then raised up toward the horizon. This was followed by the aircraft turning to the left and becoming inverted in an estimated 30-degree nose low attitude. With the nose still low, the aircraft continued around to an upright position and appeared to be in a shallow right bank. Witnesses then lost sight of the aircraft due to buildings and terrain. A May 20, 1997, work order indicated the left manifold pressure fluctuated in flight. Both wastegates were lubricated and a test flight revealed the left engine manifold pressure lagged behind the right engine manifold pressure. On June 18, 1997, the left engine differential pressure controller was noted to have been removed and replaced. This was the corrective action for a discrepancy write up that the left engine manifold pressure fluctuated up and down 2 inHg and the rpm varied by 100 in cruise. A test flight that afternoon by the accident pilot indicated the discrepancy still occurred at cruise power settings, but the engine operated normally at high and low power settings. Post accident functional checks were performed on various components. No discrepancies were noted for the left governor. The left engine differential pressure controller was damaged and results varied on each test. The left density controller was too damaged to test. The right engine density and differential pressure controllers tested satisfactory. The left and right fuel pumps operated within specifications. Both fuel servos were damaged. One injection nozzle on the left engine was partially plugged; all others flow tested within specifications.

The pilots had entered into an agreement with the 5 pax to fly them to a ski resort. The airplane owner stated that the pic, who was the company pilot, did not have permission to use the airplane, nor did the owner know the pax. The airport at the ski resort is located in mountainous terrain at 6,750 feet msl. There is no instrument approach. There is no record of any weather briefings. The airplane collided with terrain (Mt Clark) at about 6,580 feet msl approximately 7.5 miles southwest of the destination airport. Weather for the area was: mountains locally obscured 3,000 to 5,000 feet scattered to broken with tops to 9,000, and widely scattered visibilities below 3 miles with snow and rain showers. Examination of the wreckage and impact site revealed the aircraft collided with the brush and snow covered 45° slope in a level left turn. All seven occupants were killed.

After flying personnel of entertainment group to Lindbergh Field, aircraft was positioned to nearby Brown Field, since late departure was planned after noise curfew was in effect at Lindbergh. Pilot talked with FSS specialist (splst) 3 times before takeoff. He reported he did not have instruction departure procedures from airport. Splst read departure procedures on phone. On last call to FSS, pilot said he planned to depart VFR toward northeast and obtain IFR clearance after airborne (this route was toward mountains.) During call, pilot expressed concern about remaining cleared of TCA and inquired about staying below 3,000 feet. Splst agreed with pilots concerns, but after accident, splst said he thought pilot was referring to 3,000 feet agl, rather than 3,000 feet msl. Pilot had filed to takeoff at midnight, but didn't get airborne until 0141 pst. Since flight was over 1.5 hours late, IFR flight plan had 'clocked out.' As controller was reentering flight plan in computer, aircraft hit rising terrain near top of mountain, about 8 miles northeast of airport at elevation of about 3,300 feet. No deficiencies were found with aircraft or its engines. Copilot had no type rating for this aircraft, tho he reportedly had made 3 takeoffs and landings in Hawker-Siddeley HS.125. All 10 occupants were killed, among them all members of the country music 'Reba McEntire Band'.
Passengers:
Chris Austin,
Kirk Cappello,
Joey Cigainero,
Paul Kaye Evans,
Jim Hammond,
Terry Jackson,
Anthony Saputo,
Michael Thomas.