# NTSB LAX91FA132: Hawker Siddeley DH.125-1A/522, N831LC, San Diego, CA, March 16, 1991 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 16, 1991, 01:43 local (09:43 UTC) - Place: San Diego, CA - Location: 32.6393° N, 116.8476° W: Placed by OpenAirDocs from NTSB’s distance and direction from BROWN FLD MUNI (SDM), within about 3 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=32.6393&lon=-116.8476&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 10 fatal - Status: Completed, report September 11, 1992 - Report: Approved by Office Director - NTSB case key (mKey): 26986 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91FA132 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26986/pdf - Page: https://openairdocs.org/ntsb/LAX91FA132 ## Probable cause IMPROPER PLANNING/DECISION BY THE PILOT, THE PILOT'S FAILURE TO MAINTAIN PROPER ALTITUDE AND CLEARANCE OVER MOUNTAINOUS TERRAIN, AND THE COPILOT'S FAILURE TO ADEQUATELY MONITOR THE PROGRESS OF THE FLIGHT. FACTORS RELATED TO THE ACCIDENT WERE: INSUFFICIENT TERRAIN INFORMATION PROVIDED BY THE FLIGHT SERVICE SPECIALIST DURING THE PREFLIGHT BRIEFING AFTER THE PILOT INQUIRED ABOUT A LOW ALTITUDE DEPARTURE, DARKNESS, MOUNTAINOUS TERRAIN, BOTH PILOT'S LACK OF FAMILIARITY WITH THE GEOGRAPHICAL AREA, AND THE COPILOT'S LACK OF FAMILIARITY WITH THE AIRCRAFT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, climb - to cruise - planning/decision - improper, pilot in command (cause) - preflight briefing service - information insufficient, atc personnel(fss) (contributing factor) - light condition - dark night (contributing factor) - terrain condition - mountainous/hilly (contributing factor) - proper altitude - not maintained, pilot in command (cause) - lack of familiarity with geographic area, pilot in command (contributing factor) - monitoring - inadequate, copilot/second pilot (cause) - lack of familiarity with geographic area, copilot/second pilot (contributing factor) - lack of total experience in type of aircraft, copilot/second pilot (contributing factor) ## Analysis AFTER FLYING PSNL OF ENTERTAINMENT GROUP TO LINDBERGH FLD, ACFT WAS PSND TO NRBY BROWN FLD, SINCE LATE DEP WAS PLANNED AFTER NOISE CURFEW WAS IN EFFECT AT LINDBERGH. PLT TALKED WITH FSS SPECIALIST (SPLST) 3 TIMES BFR TKOF. HE RPRTD HE DID NOT HAVE INST DEP PROC FM ARPT. SPLST READ DEP PROC ON PHONE. ON LAST CALL TO FSS, PLT SAID HE PLANNED TO DEP VFR TWD NE & OBTAIN IFR CLNC AFTER AIRBORNE. (THIS RTE WAS TWD MTS.) DRG CALL, PLT EXPRESSED CONCERN ABT REMAINING CLR OF TCA & INQUIRED ABT STAYING BLO 3000'. SPLST AGREED WITH PLTS CONCERNS, BUT AFTER ACDNT, SPLST SAID HE THOUGHT PLT WAS REFERRING TO 3000' AGL, RATHER THAN 3000' MSL. PLT HAD FILED TO TKOF AT MIDNIGHT, BUT DIDN'T GET AIRBORNE UNTIL 0141 PST. SINCE FLT WAS OVR 1.5 HRS LATE, IFR FLT PLAN HAD 'CLOCKED OUT.' AS CTLR WAS REENTERING FLT PLAN IN COMPUTER, ACFT HIT RISING TRRN NR TOP OF MTN, ABT 8 MI NE OF ARPT AT ELEV OF ABT 3300'. NO DEFICIENCIES WERE FND WITH ACFT OR ITS ENGS. COPLT HAD NO TYPE RATING FOR THIS ACFT, THO HE RPRTDLY HAD MADE 3 TKOFS & LNDGS IN HAWKER-SIDDELEY DH.125. ## Aircraft - Registration: [N831LC](https://openairdocs.org/deregistered/N831LC-2011-03-21), registration cancelled 2011-03-21, S/N 25095, built 1966 (OpenAirDocs) - Reported make and model: Hawker Siddeley DH.125-1A/522 (DH.125-1A/) - Registry model: [Hawker Siddeley DH.125-1A/522](https://openairdocs.org/model/hawker-siddeley-dh-125-1a-522) (registry code 4230110) (OpenAirDocs) - Registry engine: [Rolls-Royce VIPER MK522](https://openairdocs.org/engine/rolls-royce-viper-mk522) (registry code 54552, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 25095 - Engines: Rolls-Royce VIPER 522 3330 lbs thrust turbo jet - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Prestige Tours, Inc. - Registered owner: Duncan A/C Sales Florida,Inc - Last inspection: Unknown, January 2, 2000 - Destination: AMA, AMARILLO, TX - Flight plan: IFR - Airport: SDM, Brown Field Muni, runway 8, 7,999 × 200 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 15,000 total, 150 in this make and model, 14,000 as pilot in command ## Weather - Conditions: Visual (VMC), Night/dark - Visibility: 20 statute miles - Lowest ceiling: none ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19910316005479A](https://openairdocs.org/incident/19910316005479A), Mar 16, 1991: Hwksly DH1251A522, San Diego, CA, Destroyed, 10 fatal. Collided with mountain slope 172 ft from top,VFR departure planned,IFR after takeoff,normal takeoff observed. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.