WASHINGTON – Errors by flight crew and air traffic control were to blame in the deadly crash of a medical air ambulance into Otay Mountain on Oct. 24, 2004, the National Transportation Safety Board said Tuesday.
The crash killed the captain, co-pilot and three medical crew members and destroyed the Learjet 35A, operated by Med Flight Air Ambulance. The accident occurred shortly after takeoff from Brown Field.
The board said the air traffic controller failed to alert the crew to altitude warnings as the plane was on track to fly into a mountain. The flight crew also did not follow the recommended departure procedures for taking off at night and in mountainous terrain, the board determined.
The captain and co-pilot took off straight, heading toward the mountains at an altitude of 2,300 feet, the board said.
The controller identified the airplane on the radar screen and instructed crew members to expect clearance above 5,000 feet, but then issued a heading that resulted in a flight track directly into the mountains, the board said. The mountain is at 3,556 feet altitude.
“The controller had the knowledge and opportunity to alert the flight crew to an unsafe condition, but failed to take appropriate action to do so,” the board said in a news release. The controller was not identified.
“The board has seen too often in its investigations where the flight crew and/or controllers are not performing their duties as they should,” said NTSB acting Chairman Mark Rosenker.
The board also said the pilots' fatigue was a contributing factor, though their rest and duty time were within allowable limits. At the time of the accident, the captain had been awake about 17½ hours, and the co-pilot had been awake about 16 hours, and both pilots had accumulated about 11 hours duty time.
The crew left Texas at 3 p.m. Oct. 23 for Manzanillo, Mexico, to pick up a San Diego man and one passenger and delivered them to Brown Field at 11:24 p.m. Oct. 23.
The crash killed pilot Karl A. Kolb, 56; co-pilot K. John Lamphere, 30; nurse Laura A. Womble, 47; Womble's paramedic husband, Donald, 45; and paramedic Marco E. Villalobos.
