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cover of episode 385 N666DS Citation S550 Crash in San Diego – Flying below Minimums

385 N666DS Citation S550 Crash in San Diego – Flying below Minimums

2025/5/23
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Max Trescott: 这次事故发生在凌晨，一架Citation喷气机在圣地亚哥试图进行RNAV进近时坠毁。飞机低于GPS下滑道，并在低于最低标准的高度上保持水平。我强调了在夜间和疲劳状态下理解RNAV进近的风险。从ADS-B数据来看，飞往蒙哥马利机场的仪表进近显然飞错了。飞行员可能直到飞机飞到机场附近才看到机场。虽然夜间飞仪表进近是最佳实践，但飞行员那样着陆并没有错。蒙哥马利机场的自动气象观测系统当时已停止服务，所以我们不知道机场当时的天气状况，尽管可能不太好。飞行员本应在PENYY之前下降到2500英尺，即下滑道截获高度。飞行员最终飞行的航迹低于此进近的RNAV下滑道。这位飞行员似乎飞得很快，而且速度不断变化。理想情况下，应该以恒定速度飞行下滑道或下滑路径，这样下降率和功率设置才能保持恒定。飞机似乎在像非精密进近一样飞行。飞行员甚至在最后一个数据点上仍然低于下滑道376英尺。如果您使用WAAS功能的接收器并以LPV最低标准飞行进近，则应忽略此高度。飞行员在1300到1400英尺之间的高度上保持水平，然后在PALOS之后再次开始下降，这强烈表明他正在进行非精密进近。飞机在500英尺的高度上以水平状态飞行，就像在MDA一样，这与您在进行非精密进近时会做的事情一样。从Teterboro起飞到在圣地亚哥发生事故的总时间约为七个半小时，因此疲劳可能是一个因素。生理低谷发生在凌晨2点到6点之间，人们在那时更容易犯错误。夜间事故率明显高于白天事故率，这部分原因是人们在夜间感到疲倦，他们的判断力和表现较差。在经过一夜的飞行后，任何一种情况都可能很困难。我想知道他是否把Sample Street的灯光当成了跑道灯，然后朝着它们飞去。在这种情况下，RNAV进近和ILS的最低标准相同，为什么不飞ILS呢？当您在深夜感到疲倦时，很容易误读RNAV进近上的细节，例如PALOS修正点仅适用于LNAV最低标准，而不适用于LPV最低标准。在较旧的飞机上飞行时，飞行ILS可能更有意义。飞行是一个动态环境，在一个飞机上和一种情况下有意义的答案，在飞行不同的飞机时可能不是最佳解决方案。我的目标是帮助你成为最安全的飞行员。当重大事故发生时，我们首先讨论它们，以便从中学习并预防未来的事故。我对飞行员及其家属，以及失去家园的人们表示哀悼。我们讨论事故是为了从中学习，并希望能够预防未来的事故。飞行员显然询问了其他机场的天气。管制员似乎认为飞行员的高度可能有点太高了，所以询问他是否能及时下降。飞行员显然说他可以下降，因为管制员没有发出引导，并且SoCal进近允许该航班进行RNAV GPS 28R进近。飞行员本应在PENYY之前下降到2500英尺，即下滑道截获高度。飞行员最终飞行的航迹低于此进近的RNAV下滑道。这位飞行员似乎飞得很快，而且速度不断变化。理想情况下，应该以恒定速度飞行下滑道或下滑路径，这样下降率和功率设置才能保持恒定。飞机似乎在像非精密进近一样飞行。飞行员甚至在最后一个数据点上仍然低于下滑道376英尺。如果您使用WAAS功能的接收器并以LPV最低标准飞行进近，则应忽略此高度。飞行员在1300到1400英尺之间的高度上保持水平，然后在PALOS之后再次开始下降，这强烈表明他正在进行非精密进近。飞机在500英尺的高度上以水平状态飞行，就像在MDA一样，这与您在进行非精密进近时会做的事情一样。从Teterboro起飞到在圣地亚哥发生事故的总时间约为七个半小时，因此疲劳可能是一个因素。生理低谷发生在凌晨2点到6点之间，人们在那时更容易犯错误。夜间事故率明显高于白天事故率，这部分原因是人们在夜间感到疲倦，他们的判断力和表现较差。在经过一夜的飞行后，任何一种情况都可能很困难。我想知道他是否把Sample Street的灯光当成了跑道灯，然后朝着它们飞去。在这种情况下，RNAV进近和ILS的最低标准相同，为什么不飞ILS呢？当您在深夜感到疲倦时，很容易误读RNAV进近上的细节，例如PALOS修正点仅适用于LNAV最低标准，而不适用于LPV最低标准。在较旧的飞机上飞行时，飞行ILS可能更有意义。飞行是一个动态环境，在一个飞机上和一种情况下有意义的答案，在飞行不同的飞机时可能不是最佳解决方案。

Deep Dive

Chapters
A Citation S-550 crashed in San Diego during an instrument approach to Montgomery Field. The accident resulted in fatalities and damage to nearby homes and vehicles. The investigation will focus on understanding the circumstances of the crash to prevent future accidents.
  • Citation S-550 crash in San Diego
  • Instrument approach to Montgomery Field
  • Fatalities and property damage
  • Investigation underway

Shownotes Transcript

Max Trescott examines the tragic crash of a Citation S550, N666DS, in San Diego during an attempted RNAV (GPS) 28R approach to Montgomery Field at approximately 3:46 AM. After departing Teterboro, NJ, and making a fuel stop at Wichita's Jabara Field, the pilot continued westbound overnight.

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After refueling, the flight continued to San Diego, where the Montgomery Field AWOS was inoperative, and weather was marginal. The pilot requested weather at nearby airports.

The aircraft correctly crossed the final approach fix PENYY at 2500 feet but then flew below the glide path and failed to stabilize. Speeds decreased from 200 knots to 124 knots on final, increasing workload and destabilizing the descent.

Flight path data suggests the pilot may have flown the approach as if it were a non-precision LNAV approach, mistakenly observing step-downs like the PALOS fix, which applies only to LNAV. Two level-offs occurred—one around 1300–1400 feet, then again at 500 feet—further evidence of a step-down approach profile, inconsistent with a stabilized LPV descent. Ultimately, the jet was 173 feet below LPV minimums and 440 feet below LNAV minimums when it leveled at 500 feet before crashing.

The autopilot appeared to be disengaged near the end, with irregular lateral path and a brief climb after leveling at 500 feet. Fatigue may have played a significant role, as the pilot had been flying for over 7.5 hours and the crash occurred at 3:45 AM Pacific (6:45 AM Eastern), squarely in the circadian low period when alertness suffers.

Max points out that older aircraft like this 40-year-old Citation often have non-intuitive or limited autopilot functionality for RNAV approaches. Social media commenters speculated the aircraft may have had either a non-WAAS FMS providing limited vertical guidance, or a Jet Tech STC’d Garmin 750 setup requiring autopilot workarounds. Either case complicates RNAV approach execution—especially when the pilot is tired.

Given the ILS 28R approach was available and offered the same minimums, Max questions why the pilot didn’t choose it. Even older autopilots generally handle ILS approaches more reliably than LPV. He concludes that while RNAV approaches are preferred in modern aircraft, an older jet with dated avionics at night, may warrant choosing the simpler, more robust ILS option.

Max reiterates a fundamental safety takeaway: Always tailor your approach to the aircraft and situation. What works best in a G1000 or G3000 might not be safe in a 1980s-era Citation. And never underestimate the risks of fatigue, especially during early morning hours.

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