PSA Flight 182 - Investigation

Investigation

At the nearby St. Augustine High School, a triage and command and control center was established, with its gymnasium being used as a makeshift morgue and for forensic investigation. Freezer units were used to preserve the biological remains, as San Diego was recording unusually high 100-degree temperatures at the time.

National Transportation Safety Board report number NTSB/AAR-79-05, released April 19, 1979, determined that the probable cause of the accident was the failure of the PSA flight crew to follow proper air traffic control (ATC) procedures. Flight 182's crew lost sight of the Cessna in contravention of the ATC's instructions to "keep visual separation from that traffic", and did not alert ATC that they had lost sight of it. Errors on the part of ATC were also named as contributing factors, including the use of visual separation procedures when radar clearances were available. Additionally the Cessna pilots, for reasons unknown, did not maintain their assigned east-northeasterly heading of 070 degrees after completing a practice instrument approach, nor did they notify ATC of their course change. Concerning this the NTSB report states, "According to the testimony of the controllers and the assistant chief flight instructor of the Gibbs Flite Center (owner of the Cessna), the 08:59:56 transmission from approach control to the Cessna only imposed an altitude limitation on the pilot, he was not required to maintain the 070° heading. However, the assistant chief flight instructor testified that he would expect the pilot to fly the assigned heading or inform the controller that he was not able to do so."

A dissenting opinion in the NTSB crash report by member Francis H. McAdams strongly questioned why the unauthorized change in course by the Cessna was not specifically cited as a "contributing factor" in the final report; instead, it was listed as simply a "finding", which carries less weight. McAdams also "sharply disagreed" with the majority of the panel on other issues, giving more weight to inadequate ATC procedures as another "probable cause" to the accident, rather than merely treating them as a contributing factor. McAdams also added the "possible misidentification of the Cessna by the PSA aircrew due to the presence of a third unknown aircraft in the area" as a contributing factor. The majority panel members did not cite this as a credible possibility. In an August 1982 amendment to the probable cause finding, the NTSB adopted McAdams’ viewpoints regarding both ATC and pilot failings.

The report states that in the PSA cockpit, some conversation in the cockpit was not relevant to the flight during critical phases of the flight. The report states that the conversation was not a casual factor in the accident but that "it does point out the dangers inherent in this type of cockpit environment during descent and approach to landing."

Read more about this topic:  PSA Flight 182