4 fatalities

2021-12-27: Learjet 35 (N880Z) — Aeromedevac Air Ambulance (Med Jet) — Santee-Gillespie Field, United States of America

Santee-Gillespie Field, United States of AmericaLanding (descent or approach)

On December 27, 2021, a Learjet 35 (registration N880Z) operated by Aeromedevac Air Ambulance (Med Jet) was involved in an aviation accident near Santee-Gillespie Field, United States of America during landing or approach. 4 people were killed. Investigators recorded the probable cause as: The flight crew’s decision to descend below the published MDA, cancel their IFR clearance to conduct an unauthorized circle-to-land approach to another runway while the airport was in nighttime IFR conditions, and the exceedance of the airplane’s critical… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781189815Data APIEditorial standards

During a night return flight after a patient transfer, a flight crew executed an unauthorized circle-to-land approach, descended below minimums, and struck terrain. The tower crew failed to monitor weather conditions.

Flight History

Earlier on the day of the accident, the flight crew had conducted a patient transfer from a remote airport to another nearby airport. Following the patient transfer, the flight crew departed under night conditions to return to their home base.

Approach and Maneuvering

Review of air traffic control (ATC) communication and cockpit voice recorder (CVR) recordings showed that the flight crew initially was cleared for the RNAV (GPS) runway 17 instrument approach. The approach plate stated that circling to runway 27R and 35 was not authorized at night. Following the approach clearance, the flight crew discussed their intent to cancel the approach and circle to land on runway 27R. They also discussed whether they could see the runway. After establishing visual contact with the runway, they requested to squawk VFR, and the controller cleared them to land on runway 17. The flight crew then 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. Shortly after, the flight crew asked if the runway lights for 27R could be increased, but the controller stated they were already at 100%.

Just before the controller’s response, the copilot (pilot flying) asked the captain “where is the runway.” While maneuvering onto the downwind leg, the captain told the copilot not to go lower; the copilot asked for direction to turn left, which the captain provided about 10 seconds later. The copilot said, “I see that little mountain, okay,” followed by both pilots saying “woah woah woah, speed, speed” three seconds later. Over the next five seconds, both said “go around the mountain,” and then the captain remarked “this is dicey,” with the copilot concurring. The captain then said “here let me take it on this turn,” and the copilot replied “yes, you fly.” The captain asked the copilot to watch his speed, and the copilot agreed. About one second later, the copilot said “speed speed speed, more more, more more, faster, faster…” Shortly after, the CVR indicated the airplane impacted terrain.

Data and Analysis

ADS-B data showed that when the crew reported the runway in sight, they were about 360 ft below the MDA. Upon crossing the published missed approach point, they were 660 ft below MDA. The aircraft overflew the destination airport at about 775 ft msl (407 ft agl) and entered a left downwind for runway 27R. On the downwind leg, the airplane descended to 700 ft msl, then ascended to 950 ft msl on the base leg. The last recorded ADS-B target was at 875 ft msl (295 ft agl).

Probable cause

The flight crew’s decision to descend below the published MDA, cancel their IFR clearance to conduct an unauthorized circle-to-land approach to another runway while the airport was in nighttime IFR conditions, and the exceedance of the airplane’s critical angle of attack, and subsequently entering an aerodynamic stall at a low altitude. Contributing to the accident was the tower crew’s failure to monitor and augment the airport weather conditions as required, due in part to, the placement of the AWOS display in the tower cab and the lack of audible AWOS alerting.