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Analysis of the NTSB preliminary report from the California Learjet 35A crash that killed 4

The NTSB released its preliminary findings this week into the Dec. 26 deadly crash of a Learjet 35A in El Cajon, California, operated by Med Jet LLC. The crash killed all four people on board, two pilots and two nurses. Among the report's findings is that the aircraft, maneuvering at low altitude while preparing to land, hit power lines. A summary of the NTSB Preliminary ReportThe crew of N880Z flew from Lake Havasu City Airport (HII) to John Wayne (SNA) to transfer a patient before departing John Wayne for a reposition leg back to Gillespie Field (SEE). On the reposition leg, the pilot contacted the air traffic control tower to report being established on the GPS approach to runway 17. The controller subsequently cleared the aircraft to land on runway 17.Minutes later, the pilot reported the field in sight and requested to squawk VFR. At that time, the controller did not acknowledge the request to squawk VFR and reissued a landing clearance for runway 17. The pilot then requested to land on runway 27 and canceled their IFR flight plan. The controller canceled the IFR plan and cleared the aircraft to land 27R by overflying the field and entering left traffic for the runway. A little over a minute before the last ADS-B target was recorded at 875 ft MSL, the pilot requested the runway lights to be 100%, which the controller confirmed they were already at. Automatic Dependent Surveillance Broadcast (ADS-B) showed that the airplane overflew the airport at a barometric altitude of 775 ft MSL (407 ft above the ground) before making a left downwind turn for runway 27R. On downwind, the aircraft descended to 700 ft MSL and then ascended to 950 feet on the base leg before striking power lines and impacting the yard of a home just less than 1.5 miles east of the approach end of 27R. Analysis of the El Cajon Learjet 35A crash based on the factsWhen investigating any accident which includes fatalities, it is important to not point fingers as families and loved ones grapple with their loss. As a pilot myself, I truly commend the pilots and nurses of N880Z as they provided critical on-demand air transportation to patients for years and during the pandemic.What seemed to be a routine reposition flight under Part 91 from John Wayne back to the crew's home base of Gillespie Field set off numerous alarms, as the weather at the destination deteriorated at night in the surrounding area of the arrival airport. Gillespie Field is an airport surrounded by significant terrain. Coupled with the reported visibility of 3 statute miles and mist, this approach was difficult. Circling at night with the added factor of unfavorable weather presents a hazard. Although the preliminary investigation does not point to why the crew decided to circle and cancel their IFR flight plan, some people have referred to a runway limitation for landing in their company's operations specifications of 5,000 feet. If this is the case, then landing on runway 17 would not have been possible with its 4,145-foot length in comparison to the 5,342-foot-long runway 27R. When conducting the approach, the aircraft was not at the standard jet traffic pattern of 1,500 feet above the ground when overflying the field and making the downwind turn. Instead, they continued to descend beyond the minimums of the GPS 17 approach to an altitude of about 380 feet above the ground. The aircraft executed a tight downwind turn and the pilots likely saw Rattlesnake Mountain ahead and realized they were too low. At this time, the aircraft was in a condition that made it impossible to react due to the time constraint and low airspeed prior to impacting the ground. Read the full NTSB preliminary report hereHow airplane crashes can serve as teaching pointsIt is unfortunate that it takes a crash and loss of life such as the July 2021 Challenger 605 crash in Truckee, California, and the March 2017 Learjet 35A crash in Teterboro, New Jersey, to become teachable lessons for pilots. These are accidents that business aviation pilots have familiarized themselves with, as many have studied them in recurrent or initial training and flown the flight paths in the simulator.Many of these accidents have similar root causes with some of them being a result of either Loss of Control Inflight (LOC-I) and Controlled Flight into Terrain (CFIT). These two factors serve as many safety focus areas for aviation professional organizations and flight departments so that they can take the proper steps to mitigate these hazardous events in their environment. The year 2021 showed a sign of relief in the aviation industry, bringing many more flight hours for U.S.-registered business jets and turboprops compared to the previous year. However, one thing that also increased was fatalities, with the most recent one being the El Cajon Learjet 35A crash. The four fatalities the year's total to 46, up from 18 in 2020, a year in which there were fewer flights. The record was set in 2019, with 77 killed in 16 crashes, according to Aviation International News data, which shows the previous high was in 2006, with 76 killed. Tools to be safer in the flight deckMost newer aircraft are equipped with Enhanced Ground Proximity Warning Systems (EGPWS) or other ground collision avoidance systems, but a 1985 Learjet 35A likely did not have that equipment. If the aircraft you are flying does not have advanced position awareness equipment, obtain a terrain display from a source such as Foreflight or Garmin Pilot. This can be a crucial tool in increasing one's situational awareness not only at night but also during the daytime.As pilots, we all have a duty to combat the complacency of get-there-it is, and to protect ourselves and those around us. If you are operating in a two-crew environment and you notice something unsafe, speak up about it. The cockpit voice recording was not included in the preliminary investigation, so we are unsure of whether the copilot noticed the low altitude of the aircraft and spoke out about it or even called out the minimum altitude for the approach. Practicing and instilling strong crew communication and evaluating the conditions and procedures prior to execution in your workplace or training environment can help pilots avoid tragedies like this in the future.
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