1978 — Sep 25, Pacific Southwest #182/Cessna collide, fall onto homes, fire, San Diego, CA– 144
–144 Blanchard.[1]
–153 History.com. This Day in History, Disaster, September 25, 1978. Mid-air Collision…
–150 AP. “3rd Plane May Have Confused PSA Pilot Before Fatal Crash,” Register, 9-28-1978, 1.[2]
–150 AP. “Controller Quizzed in Midair Disaster.” The Register, Orange County, 9-29-1978, 1.[3]
–150 AP. “Warning of crash ignored by tower.” Times-Standard, Eureka, CA, 9-30-1978, p. 3.[4]
–150 Eckert. “Fatal commercial air transport crashes, 1924-1981.” AJFM&P, 3/1, March 1982, Table 1.
–147 AP. “Toll 147 As Planes Collide.” The Register, Orange County, CA, 9-26-1978, p. 1.[5]
–135 PSA 182 (note that PSA originally indicated 136 onboard, but changed number)
— 2 Cessna
—>10 People on ground
–147 Jones and Lubow. Disasters and Heroic Rescues of California. 2006, p. 131.[6]
–136 Pacific Southwest Airlines
–136 passengers
— 7 crewmembers
— 2 Cessna (instructor and student)
— 9 People on the ground
–146 OJP DOJ. Community Crisis Response Team Training Manual: 2nd Ed. (Appendix D).
–145 AP. “‘Six seconds of terror straight to the ground.’” The Sun, Lowell, MA, 10-1-1978, A5.[7]
–144 AP. “Transcript of conversation to be made public…” Big Spring Herald, TX. 10-2-1978, 8A.[8]
–144 Aviation Safety Network. Accident Description. Pacific Southwest Airlines, 25 Sep 1978
–144 Derner, Phil Jr. “After 37 Years, Remembering the Horrors and Sacrifices of PSA Flight 182.”
–144 NTSB. AAR. Pacific Southwest…and…Cessna 172…San Diego…Sep 25, 1978, 1979, abstract.
–137 from the two aircraft (all); 135 on Pacific Southwest Airlines 182; 2 on Cessna.
–128 passengers on PSA 182. (p. 5)
— 9 crew of PSA 182 and the Cessna. (p. 5.)
— 7 on the ground
–144 NationMaster.com, Encyclopedia, List of Notable Accidents–Aircraft;
–144 Notable California Aviation Disasters. “The 1970s.” Oct 23, 2008 update.
–144 San Diego Union-Tribune. “After 38 years, the memories of PSA 182….” 9-25-2016.
–144 Sanders 2002, p. 177.
–136 UPI. “PSA 727 crashes in San Diego neighborhood,” Ukiah Daily Journal, 9-25-1978, 1.
Narrative Information
NTSB Synopsis: “About 0901:47 P.s.t. [Pacific standard time], September 25, 1978, Pacific Southwest Airlines, Inc., Flight 182, a Boeing 727-214, and a Gibbs Flite Center, Inc., Cessna 172 collided in midair about 3 nautical miles northeast of Lindbergh Field, San Diego, California.
“The Cessna was under the control of San Diego approach control and was climbing on a northeast heading. Flight 182 was making a visual approach to runway 27 at Lindbergh Field and had been advised of the location of the Cessna by the approach controller. The flightcrew told the approach controller that they had the traffic in sight and were instructed to maintain visual separation from the Cessna and to contact the Lindbergh Tower. Flight 182 contacted the tower on its downwind leg and was again advised of the Cessna’s position. The flightcrew did not have the Cessna in sight, they thought they had passed it and continued the approach. The aircraft collided near 2,600 ft m.s.l and fell to the ground in a residential area. Both occupants of the Cessna were killed; 135 persons on board the Boeing 727 were killed; 7 persons on the ground were killed; and 9 persons on the ground were injured. Twenty-two dwellings were damaged or destroyed. The weather was clear, and the visibility was 10 miles.
“The National Transportation Safety Board determines that the probable cause of the accident was the failure of the flightcrew of Flight 182 to comply with the provisions of a maintain-visual-separation clearance, including the requirement to inform the controller when they no longer had the other aircraft n sight.
“Contributing to the accident were the air traffic control procedures in effect which authorized the controllers to use visual separation procedures to separate two aircraft on potentially conflicting tracks when the capability was available to provide either lateral or vertical radar separation to either aircraft.” [p. 1.]
Factual Information
“1.1 History of the Flights.
“About 0816 P.s.t. on September 25, 1978, a Gibbs Flite Center Cessna 172, N7711G, departed Montgomery Field, California, on an instrument training flight. Since the flight was to be conducted in visual meteorological conditions, no flight plan was filed and none was required. A flight instructor occupied the right seat, and another certificated pilot, who was receiving instrument training, occupied the left seat.
“The Cessna proceeded to Lindbergh Field, where two practice ILS[9] approaches to runway 9 were flown….About 0857, N7711G ended a second approach and began a climbout to the northeast; at 0859:01, the Lindbergh tower local controller cleared the Cessna pilot to maintain VFR conditions and to contact San Diego approach control.
“At 0859:50, the Cessna pilot contacted San Diego approach control and stated that he was at 1,500 ft, and ‘northeastbound.’ The approach controller told him that he was in radar contact and instructed him to maintain VFR conditions at or below 3,500 ft and to fly a heading of 070°. The Cessna pilot acknowledged and repeated the controller’s instruction.
“Pacific Southwest Airlines, Inc., Flight 182 was a regularly scheduled passenger flight between Sacramento and San Diego, California, with an intermediate stop in Los Angeles, California. The flight departed Los Angeles at 0834 on an IFR flight plan with 128 passengers and a crew of 7 on board. The first officer was flying the aircraft. Company personnel familiar with the pilots’ voices identified the captain as the person conducting almost all ir-to-ground communications. The cockpit voice recorder (CVR) established the fact that a deadheading company pilot occupied the forward observer seat in the cockpit.
“At 0853:19, Flight 182 reported to San Diego approach control at 11,000 ft and was cleared to descend to 7,000 ft. At 0857, Flight 182 reported that it was leaving 9,500 ft for 7,000 ft and that the airport was in sight. The approach controller cleared the flight for a visual approach to runway 27; Flight 182 acknowledged and repeated the approach clearance.” [end of p. 2.]
“At 0859:28, the approach controller advised Flight 182 that there was ‘traffic (at) twelve o’clock, one mile, northbound.’ Five seconds later the flight answered, ‘We’re looking.’
“At 0859:39, the approach controller advised Flight 182, ‘Additional traffic’s twelve o’clock, three miles, just north of the field, northeastbound, a Cessna one seventy-two climbing VFR out of one thousand four hundred.’ According to the CVRE, at 0859:50, the copilot responded, ‘Okay, we’ve got that over twelve.’….
“At 0900:23, the approach controller cleared Flight 182 to ‘maintain visual separation,’ and to contact Lindbergh tower. At 0900:28 Flight 182 answered, ‘Okay,’ and 3 sec later the approach controller advised the Cessna pilot that there was ‘traffic at six o’clock, two miles, eastbound; a PSA jet inbound to Lindbergh, out of three thousand two hundred, has you in sight.’ The Cessna pilot acknowledged, ‘One one golf, roger.’
“At 0900:34, Flight 182 reported to Lindbergh tower that they were on the downwind leg for landing. The tower acknowledged the transmission and informed Flight 182 that there was ‘traffic, twelve o’clock, one mile, a Cessna.’
“At 0900:41, the first officer called for 5° flaps, and the captain asked, ‘Is that the one (we’re) looking at?’ The first officer answered, ‘Yeah, but I don’t see him now.’ According to the CVR, at 0900:44, Flight 182 told the local controller, ‘Okay, we had it there a minute ago,’ and 6 sec later, ‘I thin he’s pass(ed) off to our right.’ (According to the ATC transcript the 0900:50 transmission was ‘think he’s passing off to our right’ and the local controller testified that he heard, ‘he’s passing off to our right.’)
“The CVR showed that Flight 182;s flightcrew continued to discuss the location of the traffic. At 0900:52, the captain said, ‘He was right over there a minute ago.’ The first officer answered, ‘Yeah.’
“At 0901:11, after the captain told the local controller how far they were going to extend their downwind leg, the first officer asked, ‘Are we clear of that Cessna?’ The flight engineer said, ‘Suppose to be’; the captain said, ‘I guess’; and the forward jumpseat occupant said, ‘I hope.’ [end of p. 3.]
“At 0901:21, the captain said ‘Oh yeah, before we turned downwind, I saw him about one o’clock, probably behind us now.’
“At 0901:31, the first officer called, ‘Gear down.’
“At 0901:38, the first officer said, ‘There’s one underneath,’ and then 1 sec later, he said, ‘I was looking at that inbound there.’
“At 0901:28, the conflict alert warning began in the San Diego Approach Control Facility, indicating to the controllers that the predicted flightpaths of Flight 182 and the Cessna would enter the computer’s prescribed warning parameters. At 0901:47, the approach controller advised the Cessna pilot of ‘traffic in your vicinity, a PSA jet has you in sight, he’s descending for Lindbergh.’ The transmission was not acknowledged. The approach controller did not inform Lindbergh tower of the conflict alert involving Flight 182 and the Cessna, because he believed Flight 182’s flightcrew had the Cessna in sight. The aircraft collided at 0901:47.
“According to the witnesses, both aircraft were proceeding in an easterly direction before the collision. Flight 182 was descending and overtaking the Cessna, which was climbing in a wing level attitude. Just before impact, Flight 182 banked to the right slightly, and the Cessna pitched noseup and collided with the right wing of Flight 182. The Cessna broke up immediately and exploded. Segments of fragmented wreckage fell from the right wind and empennage of Flight 182.
“Flight 182 began a shallow right descending turn, leaving a trail of vaporlike substance from the right wing. A bright orange fire erupted in the vicinity of the right wing and increased in intensity as the aircraft descended. The aircraft remained in a right turn, and both the bank and pitch angles increased during the descent to about 50° at impact….
“The aircraft crashed during daylight hours, into a residential area about 3 miles northeast of Lindbergh Field…. [end of p. 4.]
“….An automated conflict detection system called “conflict alert” had been incorporated into the San Diego ARTS III to alert controllers of closures between two or more aircraft. The conflict alert system had the No. 4 priority in the computer’s executive programmer. The system monitors separation between tracked Mode C aircraft and provides an alarm when a conflict situation is detected. The conflict alert system projects a horizontal and vertical volume of airspace around a target to a future position point. Whenever the airspace envelope associated with an aircraft is predicted to overlay the airspace envelope of another aircraft, a conflict situation is likely and the controller is furnished a visual alarm–the characters “CA” blink on the top line of the data tags–and a 5-set aural alarm sounds….
“The conflict alert which sounded at the San Diego Approach control was a Type III airport area alert….
“The approach controller stated that when he heard and saw the conflict alert he discussed the situation with the coordinator. At that time Flight 182 was no longer on his frequency, the targets were beginning to merge, the aircrafts’ data blocks were overlapping, and he was not able to discern their altitude readouts. Although the data blocks could have been offset by a keyboard entry into the ARTS computer, the controller did not try to reposition them. He said that he had pointed out the traffic to Flight 182; the flightcrew had stated that they had the traffic in sight and that they would maintain visual separation from the Cessna. As far as he was concerned, there was no ‘conflict, and therefore, no further action was required. He said that the coordinator concurred with his decision, and the coordinator corroborated his testimony. At 0901:47, the approximate time of the collision, the controller did advise the Cessna again that Flight 182 was in his vicinity and had him “in sight.”
“The San Diego Approach Control’s conflict alert system was commissioned August 7, 1978. Since that time the facility has experienced an average of 13 conflict alerts per day. Some of these were nuisance alerts; however, it is not known what percentage of these alerts were nuisance alerts.
“The approach controller and coordinator stated that they were not startled by the alert, because they were accustomed to experiencing them during their duty shifts and because of the many conflict alerts where there either was “no actual conflict” or no aircraft close enough to require further action. The approach coordinator said that anytime there are two aircraft in proximity under circumstances similar to those of Flight 182 and the Cessna, one can expect the conflict alert to activate. He also said that whenever he was directly involved with a conflict alert on traffic he was controlling, he was not required to take further action or to inform the pilots of the aircraft of the conflict.” (NTSB 1979, pp. 18-20)
“….While the evidence showed that the air traffic control services provided Flight 182 and the Cessna were appropriate for the ATC environment, it also disclosed that controller personnel did not comply with the provisions of one facility directive and that two traffic advisories did not comply precisely with the prescribed procedures of FAA Handbook 7110.65A.
“Contrary to Miramar Order NRY 206G, the approach controller at San Diego approach control did not direct Flight 182 to maintain 4,000 ft until clear-of the Montgomery Field airport traffic area. The controller said that Flight 182 was outside the area when he cleared it for the visual approach and that he monitored its course on his radar. Since the flight did not enter the Montgomery Field airport traffic area, he said there was no need either to place the restriction on the flight or coordinate its passage with Montgomery Field. His determination was based on the fact that Flight 182’s course placed it south of the MZB VORTAC’s 090″ radial which, to him, constituted the end of the Montgomery Field airport traffic area and the beginning of the Lindbergh Field air traffic area. However, Flight 182’s ground track showed that it passed about .8 mile inside Montgomery Field’s airport traffic area.
“The purpose of the altitude restriction in the order was to avoid a potential conflict with Montgomery Field operations. In this instance neither aircraft was a Montgomery Field operation. One could infer that, had the restriction been applied to Flight 182, the two aircraft would have remained separated and that, even though the Cessna was not a traffic operation protected by the order, the failure to apply it was a causal factor. This inference might be valid if the controllers had taken no other action to insure that they were separated; however, they did take other action. The evidence is conclusive that the controllers pointed out the traffic to Flight 182 and then applied approved traffic separation procedures to separate the aircraft….
“In retrospect, there is little doubt that the controllers were misled (1) by their belief that Flight 182’s flightcrew were visually separating their aircraft from the Cessna and (2) by their previous
experiences with similar conflict alerts wherein no action on their part was necessary. Based on the procedures, their requirements were satisfied. They, therefore, did not try to reposition and unscramble the data blocks and reacquire the altitude readouts to further monitor the situation because they believed that visual separation was being applied.
“However, the failure of the air traffic control procedures to require that the controllers notify the pilots that their aircraft were involved in a conflict alert resulted in a less-than-optimum use of the system, particularly in a situation where visual separation procedures were being used in a terminal area. Had this requirement existed, it was possible that warnings and perhaps suggested evasive maneuvers could have been delivered to the pilots of one or even both aircraft. While the Safety Board cannot conclude that the delivery of a warning or suggested Instruction to the pilots would have altered the course of events, the failure of the procedures to require this to be done may have deprived the pilots of one more chance to avoid the collision.” (NTSB 1979, 30-31)
“Based on available evidence, the Safety Board cannot conclude whether the flightcrew of Flight 182 knew what they were required to do when they accepted the “maintain-visual-separation” clearance from the controller. In addition to maintaining proper separation from the designated aircraft, their acceptance of the clearance required them to tell the controller when they no longer had it in sight. The failure to notify controller personnel specifically that they had lost sight of the traffic could indicate that they were not aware of what was embodied in the instruction and that they may have considered it as merely another traffic advisory.
“The company’s chief pilot testified that the procedures embodied in the visual separation clearance are set forth in the regulations, which his pilots carry with them on all flights. He further testified that they are well aware of the requirements embodied within the instruction. However, the visual separation procedures are contained in the AIM and not in the Federal regulations carried by the pilots.
“He stated that AIM information is excerpted for presentation to their flightcrews in ground school, but he could not identify precisely what areas of Information were used. The evidence indicates that there may be a communications gap between pilots and controllers as to the proper
use of the ATC system. The ATC controllers are responsible for, and are required to apply, the procedures contained in Handbook 7110.65A in their control of traffic. Despite the fact that the successful use of these procedures requires a mutual understanding on the parts of pilots and controllers of the other’s responsibilities, pilots are not required to read Handbook 7110.65A. One Federal publication containing a description of the interrelationship of pilot and controller roles and responsibilities is the AIM, and this is not–by regulation–required reading for pilots. Considering the responsibilities placed on both the pilot and the controller for the safe operation in the National Air Space system, industry and the Federal Aviation Administration must take steps to insure that the pilots are made cognizant of what this relationship requires of them. Either the AIM should be compulsory reading for all pilots–at least those sections relating to ATC rules, procedures, and pilot and controller roles and responsibility–or pilots should be tested annually or semiannually on their knowledge of these procedures.
“In conclusion, the evidence indicates that even though flightcrews are still In a “see and avoid” environment, they exercise a lower degree of vigilance in areas where they receive radar assistance than in non-radar areas. Instead of attempting to seek, acquire, and then maintain visual contact with traffic, they seem to rely on the radar and radar controller to point out the aircraft, particularly an aircraft that may be in conflict with theirs. Pilots also seem to have a less-than-complete knowledge of the specific type of traffic separation services being provided. The types of traffic separation procedures available in a TRSA vary from that provided in a Stage II and Stage I area. At San Diego, depending either on the aircraft’s position or altitude, or both, the pilots could receive either Stage II or Stage III services and could pass rapidly from one area to another. Pilots must recognize the level of radar services they are receiving. In areas where traffic separation services are not being furnished they must be aware of this, and that they will be required to make a more diligent effort, not only to find conflicting traffic, but to keep previously acquired traffic in sight until they are absolutely certain it is no longer a factor to their flight. These efforts may even require that they maneuver their aircraft In a manner that will enhance their ability to sight and to maintain sight of conflicting traffic.
“Controllers seem to similarly relax vigilance. The evidence permits an inference that the vigilance of the approach controller and his standards for assessing the resolution of possible conflicts may have lowered because he believed that the flightcrew which had reported traffic “in sight” had a better view of the traffic and a better grasp on the situation than he did. This accident illustrated that this is not a hard and fast rule on which the controller can rely. Even though the pilot had assumed the burden of maintaining separation, the controller should have not assumed that the pilot’s ability to do so will remain unimpaired. He should be prepared to update the pilot’s information, and, time permitting, stand ready to alert the pilot to changes in the situation. The principle of redundancy has been recognized as one of the foundations of flight safety, and redundancy between the pilot and controller can only be achieved then both parties exercise their individual responsibilities fully regardless of who had assumed or been assigned the procedural or regulatory burden.” (NTSB 1979, 33-35)
[Blanchard: Following the “Probable Cause” paragraphs on page 36 (which are the same as noted in the abstract, there is a handwritten note: “Reconsidered & amended, 8.11/82,” and the “Probable Cause” statement has been crossed out. Following the “Safety Recommendations” on page 36 is an “Errata” which reads:]
“Aircraft Accident Report — Pacific Southwest Airlines, Inc., B-727, and a Gibbs Flite Center, Inc., Cessna 172, N7711G, San Diego, California, September 25, 1978.
“During its evaluation of the ALPA[10] Petition for Reconsideration of Probable Cause of the subject accident, The National Transportation Safety Board also reviewed the entire accident report and its supporting evidence. As a result of this reexamination, the Board concluded that the cause contained in the accident report did not reflect all the causal areas involved in the accident and has amended the probable cause. Therefore, amend the probable cause in (1) paragraphs 3 and 4 on the Technical Report Documentation Page (NTSB Form 1765.2), and (2) on page 1, paragraphs 3 and 4, and (3) page 36 of the accident report to read as follows:
The National Transportation Safety Board determines that the probable cause of this accident was the failure of the flightcrew of Flight 182 t comply with the provisions of a maintain-visual-separation clearance, including the requirement to inform the controller when visual contact was lost; and the air traffic control procedures in effect which authorized the controllers to use visual separation procedures in a terminal area environment when the capability was available to provide either lateral or vertical separation to either aircraft. Contributing to the accident were (1) the failure of the controller to advise Flight 182 of the direction of movement of the Cessna; (2) the failure of the pilot of the Cessna to maintain his assigned heading; and (3) the improper resolution by the controller of the conflict alert. [end of p. 37.]
“….McAdams, Member, dissenting
“I disagree sharply with the majority, for the reason that the inadequacies of the air traffic control system were not cited as being a probable cause of the accident.
“Although the majority does cite the inadequacies of the air traffic control system as being contributory, this is neither acceptable nor sufficient. The difference between a probable cause and a contributing factor is not semantics–there is a clear-cut distinction. A probable cause is an
act, or an omission of an act, that is in the direct line of causation and without which the accident would not have occurred, whereas a contributory factor is an event which possibly could have (but not necessarily) intervened and caused the accident. A contributing factor is not a primary cause; it is more remote and does not carry the same weight or implications as that of a probable cause.
“In my opinion, these inadequacies should have been given equal weight in the probable cause with the failure of the PSA crew to maintain visual separation rather than being merely mentioned as a contributory factor. The San Diego approach control had the capability of providing either vertical or lateral separation between IFR aircraft and participating VFR aircraft, and this procedure should have been used for the control of both aircraft. If it had, the accident would not have occurred. Apparently the majority agrees but is either reluctant or diffident to include this issue in the probable cause, since it is stated (p. 33) that if either vertical or lateral separation had been used, “….Flight 182 and the Cessna would not have collided.” Such language clearly implies that this omission was a direct cause of the accident and therefore should have been included as a probable cause.
“The controller, instead of using available procedures, gave PSA 182 a visual separation clearance which placed the pilot in an exclusively see-and-avoid situation where the last redundancy of the system was removed. The redundancy should not have been eliminated in a dense terminal traffic area such as San Diego. In my opinion, the concept of see and avoid is outmoded and should not be used in high volume terminal areas. Positive radar separation should be used with the backup, or redundancy, being the pilot’s visual ability to see and avoid. In this case, both aircraft should have remained under positive radar separation since it was available and could have provided safe separation. The failure to do so, therefore, must be considered as causal.
“Furthermore, despite strong urging on my part, the majority has not named several other factors which I consider as being contributory. It is true that the majority has included three issues which I had suggested as contributing factors, but they have been included in the report only as conclusions. For example, the majority concludes that the approach controller failed to restrict Flight 182 to a 4,000-foot altitude; obviously, that logically means the controller had a duty to issue an altitude restriction, and if such altitude restriction had been issued, it is possible the accident would not have occurred. Ergo, it is a contributing factor as well as a conclusion. A similar argument can be made with respect to the other two conclusions of the majority, i.e., heading, the Cessna failed to maintain the assigned and two separate facilities were controlling traffic in the same airspace….
“Contrary to the majority, I would cite the improper resolution by the controller of the conflict alert as contributory. The Air Traffic Control handbook, 7110.65A, requires a controller to resolve all conflict alerts. The controller failed to do this. The conflict alert was received approximately 19 seconds before the collision. Although this might be considered a rather short time, it was still sufficient to have permitted the controller to relay this information to either the Cessna or to the Lindbergh Tower or to have attempted to relay it. Irrespective of the time element, the controllers had no knowledge that there were only 19 seconds to collision, but the duty still existed. According to the majority, the reason the controllers did not take the required action was they considered that the conflict had been resolved based upon PSA 182’s response to
the traffic advisory, “Traffic in sight.” This response had been made 66 seconds prior to the conflict alert and, in my opinion, the controller should not have assumed in such an area as San Diego that the situation was static and that the conflict was resolved.
“I am at a loss to understand the reasons the majority did not include this failure as a contributing factor since it is stated in the report (p. 31), “ ..the failure of the procedures [conflict alert] to require this to be done may have deprived the pilots of one more chance to avoid the collision.” The existing procedures did require action to resolve the conflict. The issuance of a previous visual separation clearance by no means resolves a later conflict.
“The majority has now concluded that the Cessna failed to maintain the assigned heading contained in the ATC instruction, but it is not cited as a contributing factor for some unknown reason. In my opinion, the failure of the Cessna to maintain the assigned and mandatory heading was a critical factor in this accident. If the required heading had been maintained, the aircraft would have been separated 1,000 feet vertically; therefore, it is a factor to be considered as contributory. The Cessna was told to “maintain a heading of 070 and vector final approach,” which was a mandatory instruction to maintain a heading until the controller was able to vector the aircraft to a downwind leg and the final approach course. This procedure was obviously for separation reasons, since the Cessna was crossing and ascending toward the flightpath of the descending PSA 182. However, the Cessna turned to a downwind leg of 090 prematurely and beneath PSA 182. If this had not been done, the accident may not have occurred.
“In my opinion there still exists the possibility that there was a third unknown and unreported aircraft in the area which could have been mistaken by the crew of PSA 182 for the Cessna. Analysis of the CVR could be interpreted to mean that PSA never acquired the Cessna but was observing some other aircraft that was unknown or unseen by ATC. Even the majority concedes this point since they state (p. 26), the question arises as to whether the flightcrew was referring to it [The Cessna] when they called ‘traffic in sight.”‘ At 0859:39, a traffic advisory indicated the Cessna at 3 miles, and at 0859:50 PSA replied, “We’ve got that other twelve.” Whether he was referring to a previous traffic advisory or to the Cessna is not clear. At 0900:15 — 37 seconds after the first traffic advisory — another advisory was given but without aircraft identification or direction of movement, but still reporting the target at 3 miles. This mileage was corrected at the hearing, but insofar as PSA was concerned these two traffic advisories could have been related to two different aircraft since the second advisory did not either identify the target or the direction of movement, and the distance remained the same 3 miles. Obviously, the mileage would have changed by approximately 2 miles between the two aircraft, and at the time of the second advisory the separation was approximately 1 mile. This could have led PSA to assume there were two different aircraft. Further, if PSA 182 had the Cessna in sight at 0900:21 on a north-northeast course, he would have expected the target to pass off to the left of his aircraft and not to the right as he stated at 0900:50.
“Additionally, the captain reported he had seen the target at 1 o’clock before turning downwind, whereas it has been well established by the ground track of both aircraft that at this time the Cessna would have been at the 11 o’clock position. This is a difference of approximately 60 degrees, a substantial change, and could indicate the captain was looking at a target other than the Cessna, either unreported or unknown to ATC.
“At 0901:38 and 0901:39, the first officer pointed out a target, “There’s one underneath,” and “I was looking at that inbound there.” The only known and reported inbound traffic was a PSA flight that at this time had completed its landing roll and was in the 6 o’clock position to PSA 182. The first officer could not have been looking at this aircraft but must have been looking at unreported and unknown inbound traffic. Significantly, 16 ground witnesses reported additional traffic in the area that could be interpreted as being potential traffic to PSA 182. However, the important fact is there appears to have been at least one inbound aircraft that was unknown or unreported by ATC.
“Despite the conclusion of the majority that the evidence indicates there was not a third aircraft in the area, my reading of the evidence is contrary. The evidence is inconclusive on this point, and the existence of a third unknown or unreported aircraft was a distinct possibility. If there was a third aircraft and the crew of PSA 182 was watching it, this could explain the reason why the crew of PSA 182 either did not see the Cessna or subsequently lost contact with it.
“Based upon the foregoing, I would state the probable cause as follows:
“…was the failure of the flightcrew of Flight 182 to maintain visual separation and to advise the controller when visual contact was lost; and the air traffic control procedures in effect which authorized the controllers to use visual separation procedures in a terminal area environment when the capability was available to provide either lateral or vertical radar separation to either aircraft. Contributing to the accident were:
- The failure of the air traffic control system to establish procedures for the most effective use of the conflict alert system at the San Diego approach control facility.
- The failure of the controller to restrict PSA 182 to a 4,000-foot altitude until clear of the Montgomery Field airport traffic area.
- The improper resolution by the controller of the conflict alert.
- The procedure whereby two separate air traffic control facilities were controlling traffic in the same airspace.
- The failure of the controller to advise PSA 182 of the direction of movement of the Cessna.
- The failure of the Cessna to maintain the assigned heading.
- The possible misidentification of the Cessna by PSA 182 due to the presence of a third unknown aircraft in the area.” (NTSB 1979, 39-44)
(NTSB. Aircraft Accident Report. Pacific Southwest Airlines, Inc., B-727, N533PS and Gibbs Flite Center, Inc., Cessna 172, N7711G, San Diego, California, September 25, 1978 (NTSB-AAR-79-5). Washington, DC: NTSB, 4-20-1979.)
Derner: “….September 25th of 1978 was a very hot but pretty day that would end with what was, at the time, the deadliest air crash in the United States. Aside from its significance in airline history, this crash which resulted from a mid-air collision with a Cessna, is also very well known because of two images caught by photographer Hans Wendt of the aircraft plummeting to Earth with its right wing on fire….
“PSA Flight 182 was a flight from LAX to San Diego that originated in Sacramento. These short flights connecting Californian cities made it a popular commuter flight for those that worked for PSA. As a result, over 30 of their own employees were riding as passengers that day….
“While PSA Flight 182 was descending below 4,000ft, air traffic controllers informed the pilots of a small Cessna flying in the area. The pilots of both aircraft were required to “see and avoid” each other in this environment. Confusing the Cessna with a different aircraft nearby, the PSA pilots did not have this particular Cessna in sight, and they ended up descending right on top of the small propeller aircraft at 2,600 ft above the intersection of 38th Street and El Cajon Blvd.
“The top of the Cessna hit the bottom of the right wing on the 727, which is where the jet’s fuel tanks are housed. The Cessna exploded and dropped from the sky, landing close by at 32nd Street and Polk Avenue, killing both of the 2 people on board (and thankfully, no one on the ground).
“Flight 182’s damage was severe along the right wing, with Wendt’s photos clearly showing damage to the right wing’s leading edge. Damage and fire also crippled the hydraulic systems, preventing control of the aircraft. Useless attempts to correct the right-banking aircraft can be seen in high-resolution versions of the same photos, showing full-deflection of the left aileron….
“After the mid-air collision, the aircraft hit the ground 13 seconds later at a nose-down angle of 50 degrees at 300 mph. Of the 135 people that were on the aircraft, only 4 bodies were found intact. Crashing into a neighborhood, the 727 destroyed or damaged a total of 22 structures, with 7 people on the ground also perishing (including a couple in an Audi that happened to be driving down that street). Though it was the deadliest U.S. plane crash at the time (144 between the 2 aircraft and on the ground), it only held that title for a mere 8 months until American Airlines Flight 191 crashed in Chicago the following May….” (Derner, Phil Jr. “After 37 Years, Remembering the Horrors and Sacrifices of PSA Flight 182.” NYC Aviation, 9-22-2015.)
History.com: “A Pacific Southwest Airlines jet collides in mid-air with a small Cessna over San Diego, killing 153 people on this day in 1978. The wreckage of the planes fell into a populous neighborhood and did extensive damage on the ground.
“David Lee Boswell and his instructor, Martin Kazy, were in the process of a flying lesson in a single-engine Cessna 1732 on the morning of September 25, practicing approaches at San Diego’s Lindbergh Field airport. After two successful passes, Boswell aimed the Cessna toward the Montgomery Field airport northeast of San Diego.
“At the same time, Pacific Southwest Flight 182 was approaching San Diego. The jet, a Boeing 727, was carrying 144 passengers and crew members from Sacramento, after a stopover in Los Angeles. Though air-traffic controllers at Lindbergh had told Boswell to keep the Cessna below 3,500 feet altitude as it flew northeast, the Cessna did not comply and changed course without informing the controllers.
“The pilots of Flight 182 could see the Cessna clearly at 9 a.m., but soon lost sight of it and failed to inform the controllers. Meanwhile, the conflict-alert warning system began to flash at the air-traffic control center. However, because the alert system went off so frequently with false alarms, it was ignored. The controllers believed that the pilots of the 727 had the Cessna in view. Within a minute, the planes collided.
“The fuel in the 727 burst into a massive fireball upon impact. A witness on the ground reported that she saw her ‘apples and oranges bake on the trees.’ The planes nose-dived straight into San Diego’s North Park neighborhood, destroying 22 homes and killing seven people on the ground. All 144 people on the 727 were killed, as well as both of the Cessna’s pilots.” (History.com. This Day in History, Disaster, September 25, 1978. Mid-air Collision Kills 153.”)
Notable California Aviation Disasters:
“Number 1 in California’s “10 Worst Crashes”
“Date / Time: Monday, September 25, 1978 / 9:02 a.m.
“Operator / Flight No.: Pacific Southwest Airlines (PSA) / Flight 182
“Location: San Diego, Calif.
“Details and Probable Cause: Midair collision. The Pacific Southwest Airlines (PSA) Boeing B727-214 (N533PS), carrying 128 passengers and a crew of seven on an early morning flight from Sacramento and Los Angeles, was descending for a landing at San Diego’s Lindbergh Field.
“Also in the skies over San Diego that morning was a Cessna 172 Skyhawk II (N7711G) from Gibbs Flite Center, Inc., occupied by a certified pilot and a flight instructor, which had taken off from nearby Montgomery Field on a training flight.
“The Cessna had made several practice approaches at Lindbergh and was on an eastbound course to circle around and approach the same runway from the opposite direction when it was overtaken from behind by the much faster PSA jet while both planes were flying at approximately the same heading over the city’s residential North Park district.
“The Cessna impacted the forward, underside of the jetliner’s right wing, broke up, and spiraled to the ground in pieces.
“At the same moment, Hans Wendt, a local photographer covering an outdoor press event in North Park, swung his camera skyward and managed to capture two dramatic, post-collision photographs of the flaming PSA 727 jetliner as it plunged to earth several blocks away, obliterating residences and automobiles in the quiet neighborhood.
“Killed were both occupants of the single-engine Cessna, all 135 passengers and crew on board the PSA 727, and seven persons on the ground at the jetliner’s impact site. Nine other people on the ground were injured and 22 homes were destroyed or damaged.
“Despite being warned of traffic in the area, the flight crew of the PSA jet apparently lost sight of the Cessna and did not convey that fact to Lindbergh air traffic control (ATC), while ATC did not realize from radio transmissions that the PSA crew had lost track of the Cessna.
“The worst air disaster in San Diego County history as well as the worst air disaster in California to date. Fatalities: 144 — all 135 aboard the PSA jet; the 2 occupants of the Cessna; and 7 persons on the ground in North Park.” (Notable California Aviation Disasters. “The 1970s.” Oct 23, 2008 update.)
Newspapers
Sep 25: “San Diego (UPI) — A Pacific Southwest Airlines Boeing 727 with 133 persons aboard collided in flight with a small Cessna today an plunged into a residential neighborhood in possibly the worst air accident in U.S. history. All aboard the jet, a student pilot and his instructor aboard the Cessna and at least one person on the ground wee reported killed. Several others on the ground were rushed to hospitals.
“The death toll was apparently the worst for an airplane collision in U.S. history. In December 1960 two commercial planes collided over New York City, killing 128 aboard the planes and six others on the ground. The worst air disaster in history occurred March 27, 1977, at Tenerife in the Canary Islands, when two jumbo jets collided, killing 582 persons.
“The PSA plane, Flight 182 from Sacramento and Los Angeles, was on its landing approach when it collided with a Cessna 150 at an altitude of 3,000 feet, the Federal Aviation Administration said. ‘I saw the jet plane…It was smoking on the right side,’ said Phil Hopkins, a witness. ‘The right inboard engine was burning and it exploded into a fireball…and spiraled to the ground.’
“The 727 smashed into a row of houses along Dwight Street in the North Park district, about five miles from the city airport, Lindbergh Field. As it careened along the street wreckage was spewed across a wide area, injuring several persons. At least six homes were set afire. ‘There were bodies lying everywhere,’ said Barry Fitzsimmons, a photographer for the San Diego Evening Tribune who was one of the first to arrive at the scene. ‘A block of homes was on fire. It was horrible. The only thing you could see of the plane was a PSA engine. All the other wreckage appeared to level the whole block.’ Residents of the neighborhood were said to be mostly elderly persons….” (UPI. “PSA 727 crashes in San Diego neighborhood,” Ukiah Daily Journal, 9-25-1978, p. 1.)
Sources
AP (Associated Press). “3rd Plane May Have Confused PSA Pilot Before Fatal Crash,” The Register, Orange County, CA, 9-28-1978, p. 1. Accessed 7-19-2018 at:
https://newspaperarchive.com/santa-ana-orange-county-register-sep-27-1978-p-1/
AP (Associated Press). “Additional Dead.” The Register, Orange County, CA, 9-27-1978, p. 2. Accessed 7-19-2018 at: https://newspaperarchive.com/santa-ana-orange-county-register-sep-27-1978-p-2/
AP (Associated Press). “Controller Quizzed in Midair Disaster.” The Register, Orange County, CA, 9-29-1978, p. 1. Accessed 7-19-2018 at: https://newspaperarchive.com/santa-ana-orange-county-register-sep-29-1978-p-1/
AP (Associated Press). “List of Crash Dead Released.” The Register, Orange County, CA, 9-26-1978, p. 1. Accessed 7-19-2018 at: https://newspaperarchive.com/santa-ana-orange-county-register-sep-26-1978-p-5/
AP (Associated Press/Peter J. Boyer). “‘Six seconds of terror straight to the ground.’” The Sunday Sun, Lowell, MA, 10-1-1978, A5. Accessed 7-19-2018 at: https://newspaperarchive.com/lowell-sun-oct-01-1978-p-5/
AP (Associated Press). “Toll 147 As Planes Collide.” The Register, Orange County, CA, 9-26-1978, p. 1. Accessed 7-19-2018 at: https://newspaperarchive.com/santa-ana-orange-county-register-sep-26-1978-p-1/
AP (Associated Press). “Transcript of conversation to be made public today.” Big Spring Herald, TX. 10-2-1978, 8A. Accessed 7-19-2018 at: https://newspaperarchive.com/big-spring-herald-oct-02-1978-p-8/
AP (Associated Press). “Warning of crash ignored by tower.” Times-Standard, Eureka, CA, 9-30-1978, p. 3. Accessed 7-19-2018 at: https://newspaperarchive.com/eureka-times-standard-sep-30-1978-p-3/
Aviation Safety Network. Accident Description. Pacific Southwest Airlines, 25 Sep 1978. Accessed at: http://aviation-safety.net/database/record.php?id=19780925-0
Derner, Phil Jr. “After 37 Years, Remembering the Horrors and Sacrifices of PSA Flight 182.” NYC Aviation, 9-22-2015. Accessed 7-19-2018 at: http://www.nycaviation.com/2015/09/psa-flight-182/39479
Eckert, William G. “Fatal commercial air transport crashes, 1924-1981.” American Journal of Forensic Medicine and Pathology, Vol. 3, No. 1, March 1982, Table 1.
History.com. This Day in History, Disaster, September 25, 1978. “Mid-air Collision Kills 153.” Accessed 12-8-2008 at: http://www.history.com/this-day-in-history.do?action=tdihArticleCategory&displayDate=09/25&categoryId=disaster
Jones, Ray and Joe Lubow. Disasters and Heroic Rescues of California: True Stories of Tragedy and Survival. Guilford CT: Insiders Guide, an imprint of Globe Pequot Press, 2006.
National Transportation Safety Board. Aircraft Accident Report. Pacific Southwest Airlines, Inc., B-727, N533PS and Gibbs Flite Center, Inc., Cessna 172, N7711G, San Diego, California, September 25, 1978 (NTSB-AAR-79-5). Washington, DC: NTSB, 4-20-1979. Accessed 7-18-2018 at: https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR7905.pdf
NationMaster.com. Encyclopedia. “List of Notable Accidents and Incidents on Commercial Aircraft.” Accessed 12-15-2008 at: http://www.nationmaster.com/encyclopedia/List-of-notable-accidents-and-incidents-on-commercial-aircraft
Notable California Aviation Disasters. “The 1970s.” Oct 23, 2008 update. Accessed 10/18/2009 at: http://www.jaydeebee1.com/crash70s.html
Office of Justice Programs, United States Department of Justice. Community Crisis Response Team Training Manual: Second Edition (Appendix D: Catastrophes Used as Reference Points in Training Curricula). Washington, DC: OJP, U.S. Department of Justice. Accessed at: http://www.ojp.usdoj.gov/ovc/publications/infores/crt/pdftxt/appendd.txt
San Diego Union-Tribune. “After 38 years, the memories of PSA 182 crash are just as sharp and painful.” 9-25-2016. Accessed 7-19-2018 at: http://www.sandiegouniontribune.com/news/local-history/sd-me-crash-memorial-20160925-story.html
Sanders, D.E.A. (Chair), et al. The Management of Losses Arising from Extreme Events. GIRO, 2002, 261 pgs. At: http://www.actuaries.org.uk/__data/assets/pdf_file/0009/18729/Sanders.pdf
UPI (United Press International). “PSA 727 crashes in San Diego neighborhood,” Ukiah Daily Journal, CA, 9-25-1978, p. 1. Accessed 7-19-2018 at: https://newspaperarchive.com/ukiah-daily-journal-sep-25-1978-p-1/
[1] The Associated Press article of Oct 2, noted below, notes the reason for the drop of estimated fatalities from 150 to 144, the number found in the National Transportation Safety Board report on the collision (see footnote 8).
[2] “Phillip Hogue, who is overseeing the National Transportation Safety Board investigation of the Monday crash that took at least 150 lives, said both the jetliner and an unidentified twin-engine Cessna had been cleared for landing on the same runway at Lindbergh Field her.”
[3] “…a jetliner and a small plane collided, killing at least 150 persons.”
[4] “All 135 persons aboard the PSA plane were killed, as were the two occupants of the Cessna. At least 13 more persons died on the ground.”
[5] “Officials said at least 147 persons were killed in the worst air disaster in U.S. history….The FAA said none of the 135 persons aboard PSA flight 182…survived the collision. PSA had originally reported that 136 persons were aboard the jet. Both persons in the rented Cessna 172 were killed. At least 10 persons on the ground were killed by falling bodies and debris or the resulting fires….” On page 5 the paper names 128 PSA victims. Eleven additional names printed in next day’s paper, on page 2.
[6] Our total based on: “All 136 passengers and seven crew onboard the flight [182] died. Both the instructor and the student in the Cessna died. Nine people on the ground died.”
[7] Eight on the ground, 135 on PSA 182 and two on the Cessna.
[8] “San Diego (AP)….At least 144 persons died, including seven on the ground, said Deputy County Coroner Max Murphy. He said during the weekend that the death figure was revised downward from 150 to 144. He said six persons believed killed on the ground were not in their homes at the time of the crash.”
[9] Instrument Landing System.
[10] Air Lines Pilot Association.