Status: | Accident investigation report completed and information captured |
Date: | Wednesday 8 February 1989 |
Time: | 14:08 |
Type: | Boeing 707-331B |
Operator: | Independent Air |
Registration: | N7231T |
MSN: | 19572/687 |
First flight: | 1968 |
Total airframe hrs: | 44755 |
Cycles: | 12589 |
Engines: | 4 Pratt & Whitney JT3D-3B (HK) |
Crew: | Fatalities: 7 / Occupants: 7 |
Passengers: | Fatalities: 137 / Occupants: 137 |
Total: | Fatalities: 144 / Occupants: 144 |
Aircraft damage: | Destroyed |
Aircraft fate: | Written off (damaged beyond repair) |
Location: | 7 km (4.4 mls) E of Santa Maria-Vila do Porto Airport, Azores (SMA) ( Portugal)
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Crash site elevation: | 547 m (1795 feet) amsl |
Phase: | Approach (APR) |
Nature: | Int'l Non Scheduled Passenger |
Departure airport: | Bergamo-Orio Al Serio Airport (BGY/LIME), Italy |
Destination airport: | Santa Maria-Vila do Porto Airport, Azores (SMA/LPAZ), Portugal |
Flightnumber: | 1851 |
Narrative:Independent Air flight IDN1851, a Boeing 707, departed Bergamo, Italy (BGY) at 10:04 UTC for a flight to Punta Cana, Dominican Republic (PUJ) via Santa Maria, Azores (SMA).
At 13:56:47 Santa Maria Tower cleared the flight to descend to 3000 feet for a runway 19 ILS approach: "Independent Air one eight five one roger reclear to three thousand feet on QNH one zero two seven and runway will be one niner." In that transmission, the trainee controller had transmitted an incorrect QNH that was 9 hPa too high. The actual QNH was 1018.7 hPa.
After a brief pause the message resumed at 13:56:59: "expect ILS approach runway one niner report reaching three thousand." This transmission was not recorded on the voice recorder of Flight 1851, probably because the first officer keyed his mike and read back: "Were recleared to 2,000 feet and ah ... ." The first officer paused from 13:57:02 to 13:57:04, then unkeyed the mike momentarily. This transmission was not recorded on the ATS tapes.
In the cockpit, the first officer questioned aloud the QNH value, but the captain agreed that the first officer had correctly understood the controller.
After being cleared for the ILS approach the crew failed to accomplish an approach briefing, which would have included a review of the approach plate and minimum safe altitude. If the approach plate had been properly studied, they would have noticed that the minimum safe altitude was 3,000 feet and not 2,000 feet, as it had been understood, and they would have noticed the existence and elevation of Pico Alto.
At 14:06, the flight was 7.5 nm from the point of impact, and beginning to level at 2,000 feet (610 meters) in light turbulence at 250 KIAS. At 14:07, the flight was over Santa Barbara and entering clouds at approximately 700 feet (213 meters) AGL in heavy turbulence at 223 KIAS. At 14:07:52, the captain said, "Cant keep this SOB thing straight up and down". At approximately 14:08, the radio altimeter began to whine, followed by the GPWS alarm as the aircraft began to climb because of turbulence, but there was no reaction on the part of the flight crew. At 14:08:12, the aircraft was level when it impacted a mountain ridge of Pico Alto. It collided with a rock wall on the side of a road at the mountain top at an altitude of approximately 1,795 feet (547 meters) AMSL.
Probable Cause:
PROBABLE CAUSE: "The Board of Inquiry understands that the accident was due to the non-observance by the crew of established operating procedures, which led to the deliberate descent of the aircraft to 2000ft in violation the minimum sector altitude of 3000ft, published in the appropriate aeronautical charts and cleared by the Santa Maria Aerodrome Control Tower.
Other factors:
1) Transmission by the Santa Maria Aerodrome Control Tower of a QNH value 9 hPa higher than the actual value, which put the aircraft at an actual altitude 240ft below that indicated on board.;
2) Deficient communications technique on the part of the co-pilot, who started reading back the Tower's clearance to descend to 3000ft before the Tower completed its transmission, causing a communications overlap.;
3) Violation by the Aerodrome Control Tower of established procedures by not requiring a complete read back of the descent clearance.;
4) Non-adherence by the crew to the operating procedures published in the appropriate company manuals, namely with respect to cockpit discipline, approach briefing , repeating aloud descent clearances, and informal conversations in the cockpit below 10000ft.;
5) General crew apathy in dealing with the mistakes they made relating tot the minimum sector altitude, which was known by at least one of the crew members, and to the ground proximity alarms.;
6) Non-adherence to standard phraseology both by the crew and by Air Traffic Control in some of the air-ground communications.;
7) Limited experience of the crew, especially the co-pilot, in international flights.;
8) Deficient crew training, namely concerning the GPWS as it did not include emergency manoeuvres to avoid collision into terrain.;
9) Use of a route which was not authorized in the AIP Portugal.;
10) The operational flight plan, whose final destination was not the SMA beacon, was not developed in accordance with the AIP Portugal."
Accident investigation:
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Investigating agency: | DGAC Portugal |
Status: | Investigation completed |
Duration: | 3 years | Accident number: | DGAC/GPI/RA-89//05 | Download report: | Final report
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Classification:
Language/communication problems
Controlled Flight Into Terrain (CFIT) - Mountain
Sources:
» FSF Accident Prevention Vol. 52, no. 2 (Feb. 1995)
» ICAO Adrep Summary 1/94 (#33)
» ICAO Circular 262-AN/156 (80-101)
Follow-up / safety actions
DGAC Portugal issued 7 Safety Recommendations
NTSB issued 2 Safety Recommendations
Issued: -- | To: | N7231T(1) |
The Board recommends that the above be revised in accordance with the rules established in Annexes 4 and 11 to the convention on International Civil Aviation, taking account of the height of the above-mentioned RTP antenna. |
Issued: -- | To: | N7231T(2) |
The Board of Inquiry found that in the designation of the significant points of the santa Maria TMA lateral boundaries, words of the ICAO phonetic alphabet were used, which is contrary to the standards in Annex 11 to the convention on International Civil Aviation and can create confusion in the communications between aircraft and air traffic control, and that there was no designation of published routes. The Board recommends that the designation of the said points be made in accordance with the above-mentioned international standards and that designations be assigned to the above-mentioned routes. |
Issued: -- | To: | N7231T(3) |
The Board found that the use of the VSM VOR is classified as restricted, but that this information does not appear in the "AlP - Portugal, Radio Communications and Navigation Facilities - COM 2-9"; it therefore recommends that a NOTAM be published with the lateral and horizontal boundaries of the sector within which the VSM VOR should not be used, and that this information be introduced as soon as possible into the AlP - Portugal. |
Issued: -- | To: | N7231T(4) |
The Board found that there were various errors and omissions relating to the santa Maria area in the aeronautical information published in the AlP - Portugal, that some aeronautical charts do not exist and that others are out of date; it therefore recommends that all aeronautical information on the area contained in the AlP - Portugal be reviewed and updated in accordance with the standards in Annexes 4 and 15 to the Convention on International Civil Aviation. |
Issued: -- | To: | N7231T(5) |
The Board found that the World Aeronautical Chart ICAO 1:1 000 000, sheet Nos 2350 and 2351, the basic chart for all the aeronautical information on the area, is out of date and out of print since 1976; it therefore recommends the publication of an update as soon as possible. |
Issued: -- | To: | N7231T(6) |
The Board found that the procedures for entry into the Santa Maria TMA do not comply with the requirements of the Air Navigation Plan for the North Atlantic, North American and Pacific Regions (ICAO Doe. 8755/12) as regards the use of the VSM VOR in the definition of the ATS routes serving santa Maria and in the definition of holding pattern; it therefore recommends that these procedures be revised in order to comply with the planning requlrements referred to. |
Issued: -- | To: | N7231T(7) |
The Board found that in the METARs provided to Air Traffic Control, the QNH value included decimals, contrary to the recommendations in Annex 3 to the convention on International Civil Aviation and to WMO Doe. FM IS VIII - Ext METAR, which indicate that the QNH value must be rounded down, not including decimals; it therefore recommends that the procedures followed in recording the QNH value in METARs be amended, in accordance with the international standards referred to above. |
Issued: 26-APR-1989 | To: FAA | A-89-22 |
ISSUE AN AIR CARRIER OPERATIONS BULLETIN REQUIRING PRINCIPAL OPERATIONS INSPECTORS ASSIGNED TO U.S. OPERATORS ENGAGED IN INTERNATIONAL FLIGHT OPERATIONS UNDER 14 CFR PART 121 TO EMPHASIZE TO THE OPERATORS THE UNIQUE CONDITIONS OF INSTRUMENT FLIGHT OPERATIONS AT FOREIGN AIRPORTS, AND THE NEED FOR INCREASED VIGILANCE BY FLIGHTCREWS WHEN CONDUCTING INSTRUMENT APPROACH AND DEPARTURE PROCEDURES AT FOREIGN AIRPORTS. (Closed - Acceptable Action) |
Issued: 26-APR-1989 | To: FAA | A-89-23 |
REQUIRE PRINCIPAL OPERATIONS INSPECTORS ASSIGNED TO U.S. OPERATORS ENGAGED IN INTERNATIONAL FLIGHT OPERATIONS UNDER 14 CFR PART 121 TO REVIEW THEIR OPERATORS\' TRAINING PROGRAMS AND OPERATING PROCEDURES TO VERIFY THAT THE PROGRAMS AND PROCEDURES ARE ADEQUATE TO SAFELY CONDUCT INSTRUMENT FLIGHT OPERATIONS AT FOREIGN AIRPORTS. (Closed - Acceptable Action) |
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Photos
accident date:
08-02-1989type: Boeing 707-331B
registration: N7231T
accident date:
08-02-1989type: Boeing 707-331B
registration: N7231T
accident date:
08-02-1989type: Boeing 707-331B
registration: N7231T
accident date:
08-02-1989type: Boeing 707-331B
registration: N7231T
accident date:
08-02-1989type: Boeing 707-331B
registration: N7231T
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Bergamo-Orio Al Serio Airport to Santa Maria-Vila do Porto Airport, Azores as the crow flies is 3020 km (1887 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.