Accident Prevention September 1995
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FLIGHT SAFETY FOUNDATION Accident Prevention Vol. 52 No.9 For Everyone Concerned with the Safety of Flight September 1995 Crew’s Failure to Monitor Terrain Clearance After Night Takeoff Results in Collision with Mountain The pilot of the accident flight, carrying members of a country music band, had three conversations with an FAA Flight Service Station specialist before takeoff. But the conversations still left the pilot with a misunderstanding of the correct departure altitude. Editorial Staff Report The twin-turbojet Hawker Siddeley DH125-1A departed The aircraft was owned by Duncan Aircraft Sales of Florida Brown Field Municipal Airport, San Diego, California, U.S., Inc., and was operated by Prestige Tours Inc., Dallas, Texas, under visual flight rules (VFR) at night. After takeoff, the pilot U.S. The accident flight, operating under U.S. Federal contacted air traffic control (ATC) to obtain an instrument flight Aviation Regulations (FARs) Part 91, was carrying members rules (IFR) clearance for a flight plan that had been previously of country singer Reba McEntire’s band. [The U.S. Federal filed. While the pilot was communicating with ATC, the Aviation Administration (FAA) later sought action against airplane collided with rising terrain, eight miles (12.8 Prestige Tours, charging that it was operating as a “common kilometers) northeast of the airport. Visual meteorological carrier” subject to Part 135 rules.] conditions (VMC) prevailed. All eight passengers and both crew members were killed in the March 16, 1991, accident. On March 15, the accident aircraft departed Gallatin, Tennessee, U.S., with band members as passengers. The The U.S. National Transportation Safety Board (NTSB) destination was San Diego, with a fuel stop in Amarillo, Texas, concluded in its final accident report that the probable causes U.S., the report said. The report did not include the departure of the accident were “improper planning/decision by the pilot, time from Gallatin nor did it include details about the pilot’s the pilot’s failure to maintain proper altitude and clearance activities, such as duty-time and rest periods, prior to departure over mountainous terrain and the copilot’s failure to adequately from Gallatin until the accident flight. monitor the progress of the flight.” The aircraft arrived at San Diego International Lindbergh Field The report also said that “factors related to the accident were: about 1530 hours local time. The passengers deplaned, and insufficient terrain information provided by the flight service the aircraft was refueled. At 1700, the aircraft was flown to specialist during the preflight briefing after the pilot inquired Brown Field. This repositioning was necessary because of about a low-altitude departure, darkness, mountainous terrain, noise curfew restrictions that would be in effect at Lindbergh both pilots’ lack of familiarity with the geographical area and Field when the passengers departed later that night, the report the copilot’s lack of familiarity with the aircraft.” said. When the aircraft arrived at Brown Field, a different copilot was assigned to the aircraft for the return flight, the report said. A second aircraft and crew that would transport some of Transcript of Accident Aircraft the band members were also at Brown Field. Pilot’s Conversations with FAA Flight Service Station Specialist At 2315, the pilot of the accident aircraft telephoned the San Diego FAA Flight Service Station (FSS), and filed an IFR flight plan to Amarillo, with a proposed departure time of 0000 Excerpt from first telephone conversation hours (midnight), the report said. The specialist told the pilot that if he could depart VFR, he (the specialist) would provide 2322:24 FSS: Okay sir, I copy your flight plan. It’s in the a frequency to obtain the IFR clearance once airborne, the system, ready to go for ya. Give San Diego report said. Radio a call on this line for your clearance. 2322:31 Pilot: [unintelligible] can I get airborne outta here? “The FSS specialist asked the pilot if he was familiar with the Brown Field departure procedure,” the report said. “The pilot 2322:32 FSS: Pardon? stated ‘no, not really.’” A discussion followed about where to 2322:33 Pilot: Think I can get airborne outta Brown Field. locate the departure procedure for Brown Field (see transcript of conversation, at right). The specialist then issued a frequency 2322:35 FSS: Okay, if you can go out depart VFR, ah yeah, for the pilot to use after takeoff to obtain his IFR clearance, I can get a frequency ah to pick your clearance and the conversation terminated, the report said. up in the air. 2322:40 Pilot: Yeah, I like that. At 2348, the pilot called the San Diego FSS (page 3), and 2322:41 FSS: Okay, I’ll call approach and get your spoke to the same specialist. The pilot told the specialist that frequency. Are you familiar with the Brown he had reviewed the approach charts for California, and could Field departure, sir? not find a standard instrument departure (SID) for Brown Field, the report said. After some discussion, the specialist asked the 2322:46 Pilot: No, not really. pilot which runway he would depart from. The pilot said that 2322:47 FSS: Okay, it should be in your chart ah let me read he would depart Runway 8. “The FSS specialist read the it to you, because they’re very ah particular instrument departure procedure for Runway 8, and then read on the ah departures, sir. the instrument departure procedure for Runway 26,” the report 2322:55 Pilot: Okay. said. The pilot then terminated the conversation. 2322:55 FSS: Let’s see here [unintelligible]. At 0023 on March 16, the pilot called the San Diego FSS, and 2323:08 Pilot: It would be in a SID [standard instrument talked to the same specialist for the third time (page 4). The departure]. pilot “told the FSS specialist that if he followed the instrument 2323:09 FSS: It’s in the SID, yeah, just a second. Actually, departure procedure that he would enter the Terminal Control I think it’s in the STAR [standard terminal Area (TCA) without a clearance,” the report said. [All TCAs arrival route], but let’s see. have since been reclassified as Class B airspace.] “The pilot said, ‘I’m breaking into the TCA without a clearance.’ The 2323:31 Pilot: SIDs [unintelligible] government ones are FSS specialist responded, ‘That’s right. Yeah, that’s right, you right behind [unintelligible]. are.’ The pilot said, ‘So, I would be better off if I headed right 2323:33 FSS: Takeoff minimums. northeast and stayed down, say down below 3,000 [feet (915 2323:38 Pilot: No, no you’re in the wrong area. meters)].’ The FSS specialist responded, ‘Uh huh.’ The pilot then asked, ‘Do you agree with that?’ The FSS specialist said, 2323:49 FSS: Pardon? ‘Yeah, sure, that’ll be fine,’” the report said. The pilot ended 2323:41 Pilot: They’re right there where the approach plates the conversation at about 0030. are for the field. The standard instrument approach procedure chart for Brown 2323:43 FSS: Right, I know. Field showed a minimum sector altitude (MSA) of 7,600 feet 2323:44 Pilot: Right behind ’em. No, if they would be in (2,318 meters) northeast of the airport, the report said. The the charts, I’d have them anyway. MSA provides at least 1,000 feet (305 meters) of obstacle 2323:49 FSS: Oh, you have the charts there. clearance within a 25-mile (40.2-kilometer) radius of the navigation facility shown. 2323:50 Pilot: Oh yeah, I got [unintelligible]. 2323:51 FSS: Oh, okay, no problem. “Witnesses at Brown Field reported observing the passengers arrive, and reported seeing them get aboard the [accident] 2323:53 Pilot: Yeah, I’ll just look it up in the approach plates. aircraft,” the report said. The aircraft departed Runway 8 at 2 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • SEPTEMBER 1995 Brown Field at 0141. About one minute after takeoff, the pilot contacted San Diego Approach Control, “and stated that he Excerpt from second telephone was standing by for his instrument flight rules clearance,” the conversation report said. “The [approach] controller told the pilot that his clearance ‘clocked out,’ and that he would ‘put it right back in.’” The FAA computer had deleted the pilot’s IFR flight plan, 2353:49 Pilot: Yeah, I went out there and looked in the since his actual departure time was more than 90 minutes past California approach plates as far as ah some sort of special SID out of here. the proposed departure time filed in the flight plan, the report said. 2353:54 FSS: Uh huh. 2353:55 Pilot: I show absolutely nothin’ they … . The approach controller issued the pilot a transponder code, which the pilot read back. “The controller asked the pilot to 2353:58 FSS: Okay, well let me find it for you, and I’ll read it to you, because they are very particular how state his position,” the report said. “The pilot did not respond. you depart. I know you have to intercept No further transmissions were recorded from the pilot. The Mission Bay [Vortac] ah radials, and uh let’s [approach] controller received a call from the control tower at see, this is Oregon. Navy North Island, San Diego, about 0145 hours. The Navy 2354:08 Pilot: Does it show, see it doesn’t show anything in controller stated, ‘I was just watching a ah VFR squawk off of that. Brown Field, and I just noticed a large explosion over that way, and the target disappeared from my radar screen up here.’ 2354:11 FSS: Yeah, like I said, it’s ah let’s see even I have The San Diego [approach] controller responded, ‘Mine also,’” a hard time finding it in here.