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Accident Number: LAX05FA015 (NTSB)

October 24th, 2004 was a fateful day for passengers and crew members on board of N30DK, Lear Jet 35A.  The plane crashed while approaching San Diego a few minutes after taking off from the Brown Field Municipal Airport. Three doctors, the co-pilot, and the captain died on the spot. The aircraft was totally wrecked.

Situational Analysis

According to the National Transportation Safety Board, the accident was predominantly caused by the crew member’s failure to observe terrain clearance throughout the departure of the VFR. Crew Resource Management principles mandate that there should be constant communication between the crew members and the air traffic controller. Communication is the key to the effective and efficient running of an airplane. Without prior communication, an airplane cannot be controlled and will experience terrain problems.

Flight Lear Jet 35A’s accident was caused by the failure of the crew members to obtain terrain clearance directions from the air traffic controller. Consequently, it is also the responsibility of the air traffic controller to provide reasonable information about the nature of the terrain to the cabin crew members. The air traffic controller failed to do so thereby contributing to the accident.

A primary objective of Crew Resource Management is to improve self-awareness, situational awareness, decision-making, adaptability, leadership, assertiveness, mission analysis, and communication. Consequently, Crew Resource Management adopts the culture of interrogating the top leadership management of the aviation industry in order to function effectively. In its effort to ensure that the airline industry is proficient in its practice, it demands that all aviation professions should always know what is required of them in the event that a plane is on air.

Crew Resource Management procedures require that crew members should be of good health while on board. However for flight N30DK, the pilot was reported to be fatigued and was unable to make proper decisions regarding the safety of the flight. This was a major contributor to the plane crash.

Error Chain between the Cabin Crew and the Pilot

Investigations conducted after the accident revealed that the co-pilot and the captain failed to listen to the weather information on the SDM-automatic terminal information service that was recorded prior to departure time. It was argued that the pilot and his captain took note on the remark portion and disregarded the weather section even though it was of great significance to the safety of the journey.

The Pilot’s effort to contact the “Brown Field Municipal clearance’’ was in futile. A report indicated that the pilot was heard quoting that he never wanted to proceed with the journey. However, the captain insisted that they should continue because time was running out.

A large number of accidents are as a result of the error chain found between the cabin crew and the pilot. Commonly known as the chain of events, error chain refers to efficient communication process found between flight crew members. Within the aviation industry, it has been revealed that 70% of accidents are typically caused by an error on the part of the cabin crew whereas 20% of the accidents account for machine error. These mishaps are common mistakes that can be managed with effective training.

Lear Jet 35A made an error chain by failing to get adequate information about the terrain and weather situation from the ‘’Brown Field Municipal clearance’’.

Crew Fatigue and Stress

Whenever the crew is fatigued and stressed, then an accident is more likely to occur. Crew fatigue is commonly referred to as a situation whereby crew is experiencing challenges in the operation of the airplane mainly because of feeling tired and stressed out. Critical thinking is required among crew members, however, when one of them is feeling fatigued then they are unable to make definite decisions

One of the crew members of flight N30DK was feeling fatigued and made a rush decision thereby ignoring a significant information regarding the changes in weather conditions. This immensely contributed to the plane crash that killed over ten people including members of staff.

As a flight crew member, I would not have allowed the pilot who was feeling fatigued on board, however, being responsible for the safety of the aeroplane, I would have recommended that he takes plenty of rest and assign one of his colleagues to join us.

The flight’s safety is of great importance not only to the crew members but the aviation industry. Crew Resource Management concepts and principles mandate that the following should be ensured for the safety of a flight.


Leadership is all about guidance, taking responsibility, collaboration and being wise in decision-making. A captain unites crew members towards the achievement of certain goals. Crew Resource Management principles require that there should be responsible leadership among the crew members to ensure the safety of an airplane.

A pilot is expected to lead the crew members towards making effective decisions and is also required to receive information from his fellow crew members in regard to the safety of the airplane and make wise decisions. Leadership is required throughout the operation of a flight.

In the flight N30DK, there was no leadership direction or advice from the captain. He relied on the co-pilot on advice regarding flight direction but failed to get a second opinion from other crew members.

Team Work

Teamwork is essential to the achievement of a desired goal. Teamwork is commonly referred the systematic collaboration of individuals from the different field in an effort to achieve a desired goal.  Collaboration and synergism work hand in hand. Synergism is whereby crew members are allowed to contribute towards the decision-making. They intern come up with a decision that is accepted by all the crew members. Synergism can only be implemented if there is proper decision-making, effective communication and situation awareness. Teamwork is effective when synergism is applied.

Teams should have effective leadership, and their members should be ready to obey instructions. There should be leadership among the crew members. Flight N30DK had no leader, and there was no team work. The concept of synergism was not applied; this was the primary reason as to why the crew members could not make decisions regarding the weather problems and the poor terrain. Flight crew and aviation crew members are expected to adapt and learn synergism and teamwork.


Crew Resource Management requires that the crew members make wise decisions and have proper interpersonal communication strategies. CRM had decreased the amount of military and civil aviation accidents by 86%.Mishaps as a result of human error can mostly be reduced if proper Crew Resource Management standards are practiced.



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