History of Flight
On December 27, 2021, about 1914 Pacific standard time, a Gates Learjet Corporation 35A, registration N880Z, was destroyed when it crashed near El Cajon, California. The two pilots and two flight nurses were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 repositioning flight.
Earlier that day, the flight crew had flown from Lake Havasu City Airport (HII), Arizona, to John Wayne/Orange County Airport (SNA), Santa Ana, California, for a patient transfer. They departed SNA about 1856 to reposition to their home base at Gillespie Field (SEE) in El Cajon.
Communications recordings showed that at 1908:23, the pilot contacted the SEE Air Traffic Control Tower, reporting they were on the GPS approach to runway 17. The controller issued the current wind and cleared the pilot to land on runway 17. At 1912:03, the pilot reported the airport in sight and requested to squawk VFR. The controller did not acknowledge the request but reissued the landing clearance for runway 17.
At 1912:13, the pilot requested to land on runway 27. The controller asked if they wanted to cancel their IFR flight plan; the pilot replied affirmatively. The controller acknowledged the cancellation and instructed the pilot to overfly the field and enter left traffic for runway 27R, clearing them to land. At 1912:30, the pilot requested the runway lights for 27R be increased; the controller informed them the lights were already at 100 percent. No further radio communication was heard.
Cockpit Voice Recorder
The cockpit voice recorder (CVR) revealed that following the approach clearance, the flight crew discussed canceling the approach and circling to land on runway 27R. They asked each other if they could see the runway. Once visual contact was established, they requested to squawk VFR. The copilot, who was flying, asked the captain "where is the runway" just before the controller noted the lights were at 100 percent. About three seconds later, the copilot said, "perfect, I got it now." The captain asked twice more if he had the airport in sight; the copilot confirmed and commented, "we’re gonna head right down the runway" and "then we’ll make a left." About 12 seconds later, the captain stated "don’t go any lower" as the copilot asked him to call the left turn. About 13 seconds later, the captain said "make your left turn," followed by telling the copilot to straighten out 16 seconds later. The copilot asked for instructions for the left turn, and 10 seconds later the captain told him to make the turn. The copilot stated, "I see that little mountain, okay" then both said "woah woah woah, speed, speed" three seconds later. In the next five seconds, both said "go around the mountain," the captain said "this is dicey," the copilot responded "yeah it’s very dicey." Shortly after, the captain said "here, let me take it on this turn," and the copilot said "yes, you fly." The captain asked the copilot to watch his speed; the copilot agreed. About one second later, the copilot stated "speed speed speed, more more, more more, faster faster." Soon after, the CVR indicated impact with terrain.
ADS-B Data
ADS-B data showed that after departure from SNA, the flight turned left over the Pacific Ocean and flew south-southeast along the coast, climbing to about 11,000 ft msl. After passing Carlsbad, California, the airplane turned left and began descending toward SEE. At the time the flight crew reported the runway in sight, the airplane was at 1,000 ft msl. Abeam the HIRAK missed approach point, it was at 700 ft msl. The airplane overflew SEE at about 775 ft msl (407 ft agl) and entered a left downwind for runway 27R. On the downwind leg, it descended to 700 ft msl, then climbed to 950 ft msl on the base leg. The last ADS-B target was at 1914:09, at 875 ft msl, about 100 ft southeast of the accident site.
Witness Observations
Numerous witnesses near the accident site reported observing various segments of the accident sequence. One witness stated the airplane flew over their residence extremely low, made a "very hard steep turn to the left," and the wing was "basically pointing straight down to the ground" before it crashed.
Personnel Information
The captain was hired by Aeromedavac in June 2019 and upgraded to captain on July 16, 2021. His most recent proficiency check was completed on October 11, 2021.
The copilot was hired in May 2019. His initial training was completed on May 13, 2019, with recurrent training on May 6, 2020, and May 16, 2021.
Aircraft Information
The airplane was manufactured in 1985 and configured for air medical transport. It was equipped with stall warning devices, angle of attack indicators, and a control stick shaker. The L and R STALL WARNING switches on the center switch panel provided power to the corresponding stall warning system; the L STALL WARNING switch also powered the stick pusher. The stick shaker motors were attached to the front side of each control column, causing high-frequency vibration when activated. Two red L STALL and R STALL warning lights in the glareshield annunciator panel indicated impending stall or system malfunction. During flight, these lights would illuminate and flash with the stick shaker; flash duration increased with angle of attack. At or before pusher actuation, the lights appeared steady. Steady illumination at other times indicated computer loss or malfunction. The lights would illuminate when the STALL WARNING switches were off and the battery switches were on.
The wings-level stall speed at landing flap setting and a gross weight of 14,350 lb was approximately 96 kts. Stall speed increased to 119 kts in a level 50° banked turn and 134 kts in a 60° banked turn.
Meteorological Information
The most recent reported observation at SEE at 1855, about 20 minutes before the accident, indicated variable wind at 5 knots, visibility 3 statute miles, mist, broken clouds at 2,000 ft, overcast at 2,600 ft, temperature 10°C, dew point 8°C, altimeter 29.98 inHg.
One-minute AWOS data showed at 1901 visibility 2.5 miles, broken clouds at 1,400 ft, 2,100 ft, and 2,800 ft. At 1908, when the flight crew contacted SEE ATCT, visibility was 2 miles, few clouds at 900 ft, broken at 1,500 ft and 1,800 ft. At 1912, when the flight crew reported the airport in sight, visibility was 2.5 miles, few clouds at 900 ft, broken at 1,600 ft, overcast at 2,800 ft. At the accident time, visibility was 2.5 miles, few clouds at 1,000 ft, broken at 1,600 ft, overcast at 2,800 ft.
Sunset occurred at 1649, civil twilight ended at 1716.
AIRMET advisories for IFR conditions, mountain obscuration, moderate turbulence below FL180, low-level wind shear (LLWS), and moderate icing between the freezing level and 17,000 ft were active. These AIRMETs were reissued at 1913.
A pilot report at 1920 from a Citation 525 pilot reported LLWS while on a 2-mile final to Montgomery Field Airport, about 8 miles west of SEE.
14 CFR 91.155 outlines VFR weather minimums: in Class D and E airspace below 10,000 ft, visibility 3 statute miles, 500 ft below clouds, 1,000 ft above, 2,000 ft horizontal distance.
Wreckage and Impact Examination
The airplane struck a set of power lines and subsequently impacted the yard of a residential home about 1.43 nautical miles east of the approach end of runway 27R. It came to rest upright on a heading of about 118° at an elevation of about 595 ft msl. The debris path was oriented on a heading of about 310°, about 186 ft long and 90 ft wide.
The first identified point of impact was a large crater containing the forward fuselage, nose cone, portions of the instrument panel, and upper windscreen structure. The fuselage extended about 42 ft to where the elevator control horn was found. The right wing was adjacent and parallel to the fuselage. Portions of the left and right horizontal stabilizer and elevators, rudder, and right engine were found near the elevator control horn. The left wing was beyond the fuselage area. Other debris included both main landing gear, the left flap, portions of the left engine, and tip tank. All major structural components were within the debris path.
Flight control continuity was established from the cockpit to all primary flight controls.
Various engine components were located throughout the debris path, including fan blades with tearing, battering, and bending opposite rotation direction. Several fan blades were torn mid-span. Accessory gearbox internal gears and bypass stator vanes were found, along with multiple stages of axial compressor blades.
The forward fuselage and cockpit were impact and fire damaged. Control yoke remains were found. The throttle quadrant was impact damaged but intact. The flap switch was positioned at about 20 degrees. The instrument panel was impact damaged with numerous instruments displaced. One altimeter indicated 100 ft with a setting of 29.99. One airspeed indicator had a needle slap mark at about 190 knots. The caution light panel exhibited impact/thermal damage.
The left engine, examined by borescope, had missing vanes and blades in all visible compressor stages; remaining blades and vanes showed tearing and battering. The third stage nozzle vanes had battered trailing edges and pitting; metal spray on the suction side.
The right engine also showed metal spray on the suction side of the third stage nozzle vanes. Second stage axial compressor blades were bent opposite rotation direction; third stage blades had leading edge damage.
Medical and Pathological Information
Autopsies of both pilots, performed by the County of San Diego Medical Examiner, listed cause of death as "multiple blunt force injuries." Toxicology testing at the FAA Forensic Sciences Laboratory found no drugs of abuse for either pilot.
Tests and Research
A performance study based on ADS-B data estimated that bank angles greater than 60° were used to maneuver the airplane for an approach to runway 27R.
Organizational and Management Information
Aeromedavac, Inc. was a Part 135 on-demand air ambulance charter company based at SEE. At the time, it had been in business over 20 years, operating a Lear 35A and a Lear 31 for patient care, and a Lear 55 for organ transport. The company used a registered nurse and a flight paramedic for patient transport, primarily operating within a 2,000-mile radius of San Diego and into Mexico.
The company's stabilized approach criteria (General Operating Manual Section 13-3) stated that a pilot must begin formulating a decision about approach success before reaching the decision point. A stabilized approach was defined as maintaining a stable approach speed, descent rate, vertical flight path, and aircraft configuration during final stages. Company policy required a stabilized approach be established at 1,000 ft above airport elevation during VFR or IFR approaches in VMC, at the FAF during instrument approaches in IMC, and at 1,000 ft above the airport during contact approaches.
(Note: No probable cause was stated in the source.)