Managing pressure is what the responsibility of a Pilot In Command is all about.
By John and Martha King
The medivac Learjet that became a fireball on the evening of Dec. 27, 2021, at Gillespie Field in San Diego was a tragedy that resulted in four fatalities of a professional crew—two pilots and two nurses.
Such tragedies understandably make the aviation community thoughtful. Flight crews will never be able to eliminate all the risks of a flight, but such events heighten the urgency to manage them. In fact, managing the risks of flight is recognized as the primary responsibility of a flight crew.
A tool that can be helpful to flight crews in the evaluation and mitigation of the risks before a flight is known as the PAVE tool. Using the PAVE mnemonic helps pilots think about the risks of a flight by putting them into categories. Here is how the PAVE tool might have worked with this flight.
Regarding the risks associated with Pilots, among the questions to ask are about fatigue and recency of experience, both of which would reflect on the crew’s ability to perform an extremely difficult circling maneuver to land in poor weather at night. As outside observers, we don’t have the personal information to evaluate that category. But the National Transportation Safety Board (NTSB) certainly will examine those issues.
Regarding the aircraft, in this particular case one would want to consider the ability of the aircraft to maneuver at slow speeds and stop on wet runways. The Lear 35 is a very capable and efficient airplane, but due to its high approach speeds it is not an ideal airplane for maneuvering at slow speeds.
The enVironment offered up a lot to think about for this flight. It was nighttime, and there was poor weather in the area with rain, low ceilings and visibilities. Plus, there is high terrain north and east of the airport. Displaced thresholds on runways 17 and 27R result in marginal runway lengths at Gillespie Field for a Lear 35 in wet weather. At Gillespie, runway 27R is is the longest runway but the instrument approach that serves that runway is considerably out of the way for an airplane arriving from the north or west because it requires a long final from the east. Plus, it is a complicated approach with multiple step-down altitudes. And the last section of the approach is unusually steep, twice as steep as the normal angle of descent due to high terrain to the east of the airport. Although a straight-in landing on runway 27R would have the benefit of not requiring a circling maneuver, it would be an extremely difficult approach due to the poor weather, night, and the steep terrain.
Another strategy could have been to land at another airport in the San Diego area with a better approach, take ground transportation back home that evening, and pick up the airplane the next day.
Candidate airports include McClellan Palomar Airport in Carlsbad which has a slightly longer usable runway than Gillespie, an instrument landing system (ILS) which is a simpler, less steep approach with good vertical guidance, and no nearby high terrain.
Montgomery-Gibbs Executive Airport also has an ILS approach. The runway surface is plenty long, but sadly the airport operator—the City of San Diego—has deliberately taken steps to shorten the runway. The city has made the first part of the pavement unavailable for landing by declaring it a displaced threshold—shortening the available landing length by more than a quarter. The remaining pavement would be very short for the Lear 35 on a rainy day.
Also a possibility would be San Diego International Airport, which has a much longer runway and a good approach.
Leaving the airplane at another airport and returning for it the next
day would be a more expensive alternative, particularly at San Diego International with its monopoly service provider, but obviously vastly better than the alternative of a crash.
The risks of the enVironment, including landing at night in poor weather at a difficult airport, could have been avoided completely by staying overnight at their departure airport, John Wayne/Orange County, rather than flying back to San Diego that evening.
It was the end of a busy day, and it is likely the flight crew and nurses were eager to get back home for the evening. It is also likely the company wanted the airplane and crew to be back at home base that evening and available for another mission. The pressures on the flight crew to get back that evening were likely intense. Managing those pressures is what the responsibility of pilot in command is all about.
The crew chose to make an approach to runway 17 at Gillespie, which is shorter than 27R. Since an approach note stated that circling to land on runway 27R from the instrument approach was “Not authorized at night,” the crew decided to cancel their instrument (IFR) flight plan and circle visually (VFR) to land on 27R in order to have the advantage of the longer runway. When pilots of corporate jets receive their recurrent training, they are required to demonstrate the ability circle to land from instrument approaches precisely because it’s a difficult maneuver. The idea is to have training that helps minimize the risk from that maneuver. The practice is important because keeping the bank under control in low visibility is difficult due to the lack of a clear horizon.
Another key factor in the circle is the ability to keep the aircraft’s altitude under control. When a circle is conducted as part of an instrument approach, there is a minimum altitude required during the circle until the aircraft is in a position to descend normally for landing.
Crews manage this risk of descending too soon by dealing with it in a preflight briefing. Unless the crew had conducted this briefing and affirmatively stipulated a higher minimum altitude in their crew briefing, it would be easy to allow momentum to carry the airplane to, or even below, acceptable straight-in minimums.
In this case, had IFR circling to land been allowed (which would require it be done in the daytime) the circling minimum altitude would be 1,052 feet above ground level (AGL) and the straight-in minimum would be 981 feet AGL. According to the NTSB, when the crew of the Learjet canceled their IFR clearance they were at 621 feet AGL and so were already 360 feet below the minimum IFR altitude for their location. During their VFR circle they descended as low as 312 feet AGL before climbing back up to 562 feet AGL.
It was not necessary to fly this low to stay clear of the clouds. The most recent hourly weather report for Gillespie Field showed a broken cloud layer at 2,000 feet AGL.
Failing to stop the descent for a VFR circle added significant risk to the maneuver. When circling at a lower altitude you are closer to obstacles, and your sight picture for turning base and lining up with the runway is distorted. And if an unintended sink rate develops, you have less room to recover. Also, at a lower altitude your visual clues tell you you’re fast and you tend to slow down and thereby have less margin above a stall.
It is too early to know whether the contact with the ground was controlled or uncontrolled flight into terrain. But it is not too early to know that taking assertive actions to mitigate the risks imposed by the pressures to get home that evening could have resulted in better outcomes for everyone involved. Suggesting assertive risk management does not imply risk-taking behavior, but it does remind everyone that the primary responsibility of a flight crew is proactive risk management.
John and Martha King are the founders of San-Diego-based King Schools, which provides aviation training programs and risk management courses to pilots worldwide.
The Monday morning quarterbacking is interesting, None of us know what was going on in the mind of the crews or all of their actions in the cockpit. The evidence is they elected to circle to Runway 27 because it twas the longest runway to meet aircraft performance.. In my opinion a Circling approach is the one of the most dangerous things you can do in an airplane. Add some rain low visibility and night to the equation and the risk factor goes up. It appears form what reports i have read and radar reports reviewed. that the probably over banked the aircraft at a low airspeed and altitude, and due to the steep bank it stalled and impacted the ground.
Why are we so quick to judge and point fingers when we may not have all the information.
The entire flight was a bad decision when the Lear left the chocks at John Wayne. Circling approaches are hard even in good weather in a high performance aircraft. We all also know during retraining, you learn very little about a real circling approach. The school just teaches you how to satisfy the simulator (turn right doe 20 seconds, parallel for until base, autopilot still on until turning inbound and then full flaps and autopilot off.) There are no obstacles except a few. They teach you to look for land marks out the window ie in ANK you look for the big fuel tank. The crew took off with a very narrow margin of safety window. As we all know a short and quick trip in high density airspace is a handful. A lot of moving parts happening real fast which leaves very little room for error. We may all be Monday morning quarterback and if the crew could get a do over, I’m sure they’d have left the airplane at SMO. Also, I saw addressed in an above mentioned article about the pressures put on the crew to make the trip. We’ve all been guilty of this and we need to make the decisions early on to prevent this type of outcome. At the end of the day, I’m sure management and crew will be over it.
Correction. SMO when I meant to say SNA.
The E in External Pressure should be in all caps and red letters. Time and again we see this tragedy unfold. I don’t have the answer for the pressure placed on us to finish the mission. Failure is more frightening than death.
Short and sweet, PAVE is an everyday tool for every flight, and should be in every pilot’s flight bag. Thanks Martha and John for helping move pilot decision making into standard teaching curriculums. The science of ADM is a game changer that has made all of us better pilots.
John and Martha, Thank you. Your work is awesome. This crash (not an accident) was sooooo preventable. The other option that was on the table was circling west for 09L all while remaining on the IFR flight plan. Of course that would mean the right seater would be the only one with a view…..which opens more questions about the crew qualifications. The tower knew instantly what the pilots intentions were following the cancelation of IFR. This leads one to conclude that this operation was common-place.
This crash was unquestionably caused by pilot(s) error. The elephant in the room is hard to talk about though, but we as an industry needs to take a proactive approach to curbing these cases of horribly bad judgement. This wasn’t an accident, it was willful misconduct resulting in death. It was willful misconduct because a normal person would not have circled for 27R in an LR35 at night. Willful misconduct leading to death is a felony. The Director of Operations, who had operational control over this flight, should be in jail seated next to the Directors of Operations of the Kobe Bryant flight, and the Truckee Challenger flight.
We don’t need any more regulations. We need people to be held responsible for their actions. Enuf is enuf.
Excellent suggestion for alternate circling and staying IFR, but I couldn’t disagree more about jailing the OPS director. The PIC is exactly that – and must remain so.
Completely agree. No need for the yet another mnemonic that I need a mnemonic to remember what it stood for. This was willful bad decision making. I wouldn’t do that in a Cessna 172.
Wilfull misconduct requires a specific INTENT to cause harm. No way this crew INTENDED to do harm. Their state of mind (“mens rea”) was either negligent, gross negligent or reckless, but certainly not INTENTIONAL. I’m a former prosecutor and can tell you flat out that a prosecution for intentional misconduct, i.e., murder) would not make it past a pre-trial Motion to Dismiss and would never get to a jury. But a prosecution for manslaughter (“reckless disregard of a known or obvious risk”) probably would. In any event, persons or entities other than the crew members who made the fateful decisions that night would never be charged with a crime since they had no role at all in making the decisions that resulted in a loss of life.
No proof of this but I have a bunch that the captain was on the radio and perhaps the presumably, less experienced, copilot was flying (typical of an empty leg) and while the captain was communicating made some excursions which, when noticed, were unrecoverable.
Excellent analysis and commentary. Since becoming familiar with the “PAVE” checklist I use it every time I fly (even if I am just doing pattern work!). It works.
Such a tragedy to happy to professionals trying to help people. Should never have happened. This is not too far from us at KVNY. So sad.
Not sure what Sectional you are using to gauge your location to Gillespie but KVNY is nowhere near KSEE… have a looKSEE for yourself.