Individually Owned: 151,845
Corporate Owned: 143,699
Brown Field Municipal Airport
Aircraft Accident/Incident Report
San Diego, California 92154
Sunday, October 24, 2004 PDT
NTSB Narrative Summary Released at Completion of Accident
The Safety Board adopted the final report of this accident investigation, including the analysis and probable cause, on May 23, 2006. The Board's full report is available on : http://www.ntsb.gov/publictn/2006/AAB0605.pdf
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.
NTSB Probable Cause Narrative
The failure of the flight crew to maintain terrain clearance during a VFR departure, which resulted in controlled flight into terrain, and the air traffic controller's issuance of a clearance that transferred the responsibility for terrain clearance from the flight crew to the controller, failure to provide terrain clearance instructions to the flight crew, and failure to advise the flight crew of the MSAW alerts. Contributing to the accident was the pilots' fatigue, which likely contributed to their degraded decision-making.
Event Information
| Type of Event | Accident |
| Event Date | 10/24/2004 |
| Event Day of the Week | Sunday |
| Time of Event | 25 |
| Event Time Zone | Pacific Daylight Time |
| Event City | San Diego |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 92154 |
| Event Date Year | 2004 |
| Event Date Month | 10 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 323407N |
| Event Location Longitude | 1165040W |
| Event Location Airport | Brown Field Municipal Airport |
| Event Location Nearest Airport ID | SDM |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 8 |
| Degrees magnetic from airport | -- |
| Airport Elevation | 526 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | |
| Direction of event from weather observation facility (degrees) | 270 |
| Weather Observation Facility ID | SDM |
| Elevation of weather observation facility | 526 |
| Distance of event from weather observation facility (units?) | 8 |
| Time Zone of the weather observation | -- |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 2100 |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | -- |
| Sky Condition for Lowest Ceiling | Overcast |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 8 |
| Air Temperature at event time (in degrees celsius) | 14 |
| Dew Point at event time (in degress fahrenheit) | 12 |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | -- |
| Wind Speed (knots) | -- |
| Wind Velocity Indicator | Calm |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.93 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 5 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 5 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 20087 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | Oct 24 2004 12:00AM |
| NTSB Notification Time | 130 |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | May 26 2006 7:03AM |
| User who most recently changed record | NTSB\JOHB |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | FSDO San Diego, California |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N30DK |
| NTSB Number | LAX05FA015 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | No |
| Damage | Destroyed |
| Aircraft Fire | Ground |
| Aircraft Explosion | Ground |
| Aircraft Manufacturer's Full Name | Learjet |
| Aircraft Model | 35A |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 345 |
| Certified Max Gross Weight | 18300 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 7 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | AAIP |
| Date of Last Inspection | Aug 1 2004 12:00AM |
| Airframe hours since last inspection | 132 |
| Airframe Hours | 10047.6 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | Med Flight Air Ambulance |
| Aircraft Owner Street Address | 2301 Yale Blvd. SE |
| Aircraft Owner City | Albuquerque |
| Aircraft Owner State | NM |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 87106 |
| Operator is an individual? | No |
| Operator Name | -- |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | -- |
| Operator Zip code | -- |
| Operator Code | -- |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Positioning |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | SDM |
| Departure City | San Diego |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 23 |
| Departure Time Zone | PDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | ABQ |
| Destination City | Albuquerque |
| Destination State | NM |
| Destination Country | USA |
| Specific Phase of Flight | Takeoff - initial climb |
| Report sent to ICAO? | No |
| Evacuation occurred | No |
| Date of most recent change to record | Feb 23 2006 4:20PM |
| User who most recently changed record | COOS |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | 8L |
| Runway Length | 7999 |
| Runway Width | 150 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |