A series of mistakes by an air traffic controller at San Diego’s Brown Field was likely what caused two planes to collide last year, killing all five on board, a federal report says.

Contributing to the accident was the two pilots’ failure to see each other in time to avoid a collision, the National Transportation Safety Board said.

The report on the Aug. 16, 2015, crash was issued last month, along with safety alerts calling for extra training for air traffic controllers and advice that pilots use cockpit technologies that may help avoid a collision.

A Cessna 172M was piloted by Qualcomm executive Michael A Copeland. An experimental Sabreliner was piloted by Jeffrey Percy, with co-pilot James Hale and passengers Carlos Palos and John Kovach also on board.


Four of those in the Sabreliner were employees of military contractor BAE Systems, while Hale worked as a BAE contract employee.

The planes collided about a mile northeast of Brown Field Municipal Airport in Otay Mesa. Debris was scattered across brushy hillsides, and all five men were found dead amid the wreckage.

The NTSB said the probable cause of the accident was the local air traffic controller’s “failure to properly identify the aircraft in the (departure) pattern and to ensure control instructions provided to the intended Cessna on downwind were being performed before turning Eagle1 (the Sabreliner) into its path for landing.”

The air traffic controller, who was not named in the report, had 37 years’ experience: five with the Air Force, 24 years with the Federal Aviation Administration and eight years with Serco Inc., a government services contractor hired by the FAA to provide controllers at some airports, including Brown Field.


The report added that a contributing factor was the controller’s “incomplete situational awareness” when he took over communications from a trainee due to the high workload at the time of the accident.

A third factor was the inherent limitations to a long-standing FAA “see and avoid” concept of relying on pilots to keep each other in view.

The weather, warm and clear, was not a factor, and the pilots and co-pilot had no drugs or alcohol in their systems.

The families of all five men have sued Serco for wrongful death. BAE was also named as a defendant in some of the lawsuits.


Kovach’s family appears to have reached a settlement on undisclosed terms, according to San Diego Superior Court documents. The four other lawsuits appear headed for trial in August.

Serco representatives, reached at their Virginia headquarters, did not provide a comment on the lawsuits or the NTSB findings.

An FAA spokesman said Serco continues to hold a contract to provide air traffic controllers at Brown Field, which the city of San Diego owns. The city is not named in the lawsuits.

The report set out a minute-by-minute account of the events leading up to the collision.


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Copeland had left Montgomery Field in Kearny Mesa earlier and at 10:49 a.m. requested approval to conduct touch-and-go landings at Brown Field. His request was granted.

The Sabreliner crew was returning to Brown Field after a mission. It was starting to land after the Cessna completed one landing and took off again.

The air traffic controller was working with a trainee that day.


When the workload started to build, the experienced man took over from the trainee at 10:59 a.m. He was in communications with nine aircraft on the ground and in the air — two more than he was personally comfortable with, he later told NTSB investigators.

At that point, the NTSB said, he should have handed off control of some aircraft or directed traffic away from Brown Field.

Over the course of two minutes, the controller mistook several planes and gave them wrong instructions, which he and the pilots quickly corrected, the report said. He gave approval for another Cessna 172 to take off.

The controller saw the Sabreliner, called Eagle1, approaching the airport and two Cessnas, including the one Copeland was piloting, in its vicinity.


“He was aware of the potential conflict between two aircraft, even though he did not have the accurate mental picture of which Cessna was which,” the NTSB said. The agency said the controller should have issued a safety alert to Eagle1 to climb immediately.

As Eagle1 kept approaching, its pilot commented, “Wow, he’s like panicking,” as heard on the cockpit recorder, the report said.

One passenger was recorded seconds later saying, “See him right there?” The flight crew also reported to the air traffic controller that they had traffic in sight on their left and right.

The controller, thinking he was talking to Copeland in the Cessna flying closest to the airport, mistakenly radioed the other Cessna, which was further away. That second pilot heard instructions to make a right 360-degree turn over the airport, and he began making that turn.


After clearing Eagle1 to land, the controller looked up and noticed a Cessna that was not making a right turn. He again contacted the wrong pilot, who again confirmed he was turning. Copeland, who should have been told to turn, was not given the instruction.

At that time, Eagle1’s pilot was recorded saying, “I see the shadow but I don’t see him.”

At 11:03 a.m., the controller transmitted Copeland’s plane ID number, and Copeland repeated the number. Four seconds later, the controller asked Copeland if he was still “on the right downwind leg,” turning right. Copeland did not answer.

The controller and the trainee then saw Eagle1 and Copeland’s plane collide.


The Sabreliner’s right wing hit the left side of the Cessna’s engine.

The NTSB tried to reconstruct the chain of events by creating animations of the views the two pilots would have had before crashing. They found that the fields of view were limited and partly obscured.

In April, the FAA published an update to its advisory on a pilot’s role in avoiding collisions by advocating cockpit warning systems.

A separate FAA order reminds air traffic controllers that their highest priority is to separate aircraft and issue safety alerts as needed.