NTSB Blames Controller, Crew, For Air Ambulance Crash

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The NTSB determined on Tuesday that errors by the flight crew and an air traffic controller led to the crash of a Learjet 35A near San Diego in October 2004. The jet was being operated as an air ambulance. Both pilots and all three medical crewmembers were killed. The board determined that the probable cause of the accident was the flight crew's failure to maintain terrain clearance during a VFR departure at night, which resulted in controlled flight into terrain. But the air traffic controller shared the blame, the NTSB said. The controller provided the flight crew with a heading and told them to maintain VFR and expect an IFR clearance above 5,000 feet. The captain acknowledged the heading instructions; however, the heading issued by the controller resulted in a flight track that allowed the airplane to continue directly toward the mountains. Further, the controller's computer system generated aural and visual alerts on the display, yet the controller took no action to warn the flight crew. "The Board has seen too often in its investigations where the flight crew and/or controllers are not performing their duties as they should," said NTSB Acting Chairman Mark Rosenker. "We cannot emphasize enough the importance of following the appropriate procedures to help ensure safety." Contributing to the accident was the pilots' fatigue, the NTSB said.