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WPR22FA068 · Gates Learjet Corporation 35A

27 Dec 2021 · El Cajon, CA, United States

Aeromedevac Gates Learjet Corporation 35A · Accident: loss of control in flight on approach

From John Wayne Orange County International Airport (SNA) to an unrecorded destination

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Event

NTSB case
WPR22FA068
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
4 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Gates Learjet Corporation 35A

Aircraft type
Learjet 35
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N880Z
Operator
Aeromedevac
Onboard fatalities
Unknown
Route
From John Wayne Orange County International Airport (SNA), Santa Ana, CATo not recorded
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Approach · VFR pattern base
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Loss of control in flight
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Destroyed

Cause areas

  • Aircraft › Aircraft oper/perf/capability
  • Environmental issues › Conditions/weather/phenomena
  • Environmental issues › Operating environment
  • Environmental issues › Task environment
  • Personnel issues › Action/decision
  • Personnel issues › Psychological
  • Personnel issues › Task performance

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

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.

Review of air traffic control (ATC) communication, as well as cockpit voice recorder (CVR) recordings, showed that the flight crew initially was cleared on the RNAV (GPS) runway 17 instrument approach. The approach plate for the instrument approach 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. Additionally, the flight crew discussed with each other if they could see the runway. Once the flight crew established visual contact with the runway, they requested to squawk VFR, then the controller cleared them to land on runway 17. The flight crew then requested to land on runway 27. The controller asked the pilot if they wanted to cancel their instrument flight rules (IFR) flight plan, to which the pilot replied, “yes sir.” The controller acknowledged that the IFR cancellation was received and instructed the pilot to overfly the field and enter left traffic for runway 27R and cleared them to land.

Shortly after, the flight crew asked the controller if the runway lights for runway 27R could be increased; however, the controller informed them that the lights were already at 100 percent. Just before the controller’s response, the copilot, who was the pilot flying, then asked the captain “where is the runway.” As the flight crew maneuvered to a downwind leg, the captain told the copilot not to go any lower; the copilot requested that the captain tell him when to turn left. The captain told him to turn left about 10 seconds later. The copilot stated, “I see that little mountain, okay” followed by both the captain and co-pilot saying, “woah woah woah, speed, speed” 3 seconds later. During the following 5 seconds, the captain and copilot both stated, “go around the mountain” followed by the captain saying, “this is dicey” and the co-pilot responding, “yeah it’s very dicey.” Shortly after, the captain told the copilot “here let me take it on this turn” followed by the co-pilot saying, “yes, you fly.” The captain asked the copilot to watch his speed, and the copilot agreed. About 1 second later, the copilot stated, “speed speed speed, more more, more more, faster, faster… .” Soon after, the CVR indicated that the airplane impacted the terrain.

Automatic dependent surveillance – broadcast (ADS-B) data showed that at the time the flight crew reported the runway in sight, they were about 360 ft below the instrument approach minimum descent altitude (MDA), and upon crossing the published missed approach point they were 660 ft below the MDA. The data showed that the flight overflew the destination airport at an altitude of about 775 ft mean sea level (msl), or 407 ft above ground level (agl), and entered a left downwind for runway 27R. While on the downwind leg, the airplane descended to an altitude of 700 ft msl, then ascended to an altitude of 950 ft msl while on the base leg. The last recorded ADS-B target was at an altitude of 875 ft msl, or about 295 ft agl.

Examination of the accident site revealed that all major structural components of the airplane were present within the wreckage debris path. Wreckage and impact signatures were consistent with a nose-low impact with terrain. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.

Information provided during interviews with the controller in charge (CIC), revealed that he was aware that the weather had been marginal visual flight rules (MVFR) for a while leading up to the time of the accident. He recalled the weather at the time of the accident as still being MVFR and did not recall it ever becoming IFR, and further stated he had not observed a change on the automated weather observing system (AWOS) display, which was located in the back of the tower cab and did not have an audible alert when weather conditions changed. At the time of the accident, the CIC was operating in a position responsible for conducting Limited Aviation Weather Reporting Station (LAWRS) augmentation.

According to information provided during interviews with the local control (LC) controller, he was aware that the weather had been marginal most of his shift. He recalled the weather at the time of the accident as still being MVFR and did not recall it ever becoming IFR. At the time of the event, he was not directly responsible for conducting LAWRS augmentation.

The AWOS one-minute data showed that the visibility had decreased to less than 3 miles visibility 7 minutes before the flight crew had checked in with tower controller on the instrument approach. The visibility remained below 3 miles throughout the instrument approach, cancelation of the IFR clearance, and accident sequence.

A performance study was conducted to determine the estimated airspeed, bank angle, and angle-of-attack. The study indicated that the flight crew likely exceeded the wings’ critical angle-of-attack, and the airplane entered an accelerated aerodynamic stall at a low altitude that would have not allowed time for recovery.

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record WPR22FA068
Event ID
20211228104445
Case number
WPR22FA068
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: local date, investigation status, cause areas. Values present in the bulk record are kept.
  • The date is the local date; the NTSB stores the UTC date 2021-12-28.
  • API snapshot SHA-256: 3a3a9ffab67ddf8b8108c4fa2b5f6ec7096f3d5bd53eb380cc761842569779f6; retrieved 2026-09-15T07:39:43.190Z.