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Marginal Decisions

This image from the NTSB's preliminary report into this accident depicts the Learjet's flight path and altitudes, and supplies annotations of communications during the approach.
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Key Takeaways:

  • The article analyzes a Learjet 35 crash at Gillespie Field, where the crew canceled IFR to fly a visual pattern at night in marginal VFR conditions, despite challenging terrain and approach restrictions (no night circling to the intended runway).
  • It highlights how "mission completion bias" and complacency with unsafe "standard practices" can lead pilots to compromise safety, especially when mentally "boxed in" without considering alternatives like alternate airports or going missed.
  • Key takeaways include the importance of strictly adhering to Terminal Instrument Procedures (TERPS), setting and respecting personal weather minimums (especially for night VFR), and maintaining flexibility by always having options (e.g., going around, diverting) to ensure sound aviation decision-making and reduce risk.
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In late December 2021, I was giving upset recovery training to a student. We were done with our work in the practice area and were returning to base at Montgomery-Gibbs Executive Airport in San Diego. Weather included unlimited visibility and scattered clouds. We picked up the ATIS and were heading toward the airport. A few minutes later, seated in the rear seat, I heard my student come over the intercom to confess that he didn’t really know where we were or how to get back home. This student has hundreds of hours of flying experience in the San Diego area, and I regard him as a serious and highly competent pilot. Still, the scattered clouds were obscuring some of the landmarks we subconsciously use to orient ourselves, and this made pilotage difficult.

A few days later, at the nearby Gillespie Field Airport (KSEE), a Learjet 35 crashed as it attempted to land. The Lear’s crew cancelled IFR on short final, and was flying a VFR pattern to a landing on another runway when the airplane collided with terrain. All four occupants aboard this aeromedical flight—two flightcrew members and two flight nurses—died in the accident. Of course, NTSB and FAA investigations have just begun, and we still do not know the specific cause of this crash. Still, the facts we know reveal several factors that may have contributed to the accident. Considering them can help us avoid similar accidents in the future.

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