Narrative:
Flight IBT1278 departed Madrid (MAD) at 06:35 for a flight to Bilbao (BIO), with 2873 kg of cargo on board. The aircraft climbed to its assigned cruising altitude of FL220, which was reached at 06:53. Permission to descend was given at 07:12 and at 07:23 the crew started an ILS approach to runway 30. Two minutes later the captain experienced control problems, which he attributed to an autopilot malfunction. An increase in the rate of descent went unnoticed by the crew who tried to find out the cause of the control problems. As the plane was descending over mountainous terrain, the GPWS alarm sounded three times. The approach controller then asked if the flight was established on the localizer and ILS glidepath. The copilot then replied that they had captured the localizer. Approach Control then instructed the crew to contact Bilbao Tower. Contact was not established however. The copilot noticed that they had not captured the glidepath and informed the captain. The airplane´s speed and rate of descent were reduced and a smooth climb was initiated. Six seconds later the airplane flew into the side of the Monte de Santa Marina, some 18 nm (33 km) from Bilbao Airport. The mountain has an altitude of 675 m (2215 ft).
CAUSAS: "El accidente se produjo por no mantener la aeronave una separación adecuada con el terreno cuando se realizaba la maniobra de aproximación al aeropuerto de destino, como consecuencia de haber focalizado la tripulación su atención en la desconexión del piloto automático . A partir del momento en que surgieron dificultades con los mandos de vuelo, la tripulación no realizó los procedimientos estándar de operación establecidos por el explotador de la aeronave."
Controlled Flight Into Terrain (CFIT) - Mountain
accident date: 14-01-2002
type: Embraer 120RT Brasilia
registration: EC-GTJ
accident date: 14-01-2002
type: Embraer 120RT Brasilia
registration: EC-GTJ
| Status: | Accident investigation report completed and information captured |
| Date: | Monday 14 January 2002 |
| Time: | 07:28 |
| Type: |  Embraer EMB-120RT Brasilia |
| Operator: | Ibertrans Aérea |
| Registration: | EC-GTJ |
| MSN: | 120024 |
| First flight: | 1986 |
| Total airframe hrs: | 23578 |
| Cycles: | 29468 |
| Engines: | 2 Pratt & Whitney Canada PW118 |
| Crew: | Fatalities: 2 / Occupants: 2 |
| Passengers: | Fatalities: 1 / Occupants: 1 |
| Total: | Fatalities: 3 / Occupants: 3 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | 2 km (1.3 mls) SE of Zaldívar ( Spain)
|
| Phase: | En route (ENR) |
| Nature: | Cargo |
| Departure airport: | Madrid-Barajas Airport (MAD/LEMD), Spain |
| Bilbao Airport (BIO/LEBB), Spain | |
| Flightnumber: | 1278 |
Flight IBT1278 departed Madrid (MAD) at 06:35 for a flight to Bilbao (BIO), with 2873 kg of cargo on board. The aircraft climbed to its assigned cruising altitude of FL220, which was reached at 06:53. Permission to descend was given at 07:12 and at 07:23 the crew started an ILS approach to runway 30. Two minutes later the captain experienced control problems, which he attributed to an autopilot malfunction. An increase in the rate of descent went unnoticed by the crew who tried to find out the cause of the control problems. As the plane was descending over mountainous terrain, the GPWS alarm sounded three times. The approach controller then asked if the flight was established on the localizer and ILS glidepath. The copilot then replied that they had captured the localizer. Approach Control then instructed the crew to contact Bilbao Tower. Contact was not established however. The copilot noticed that they had not captured the glidepath and informed the captain. The airplane´s speed and rate of descent were reduced and a smooth climb was initiated. Six seconds later the airplane flew into the side of the Monte de Santa Marina, some 18 nm (33 km) from Bilbao Airport. The mountain has an altitude of 675 m (2215 ft).
Probable Cause:
CAUSAS: "El accidente se produjo por no mantener la aeronave una separación adecuada con el terreno cuando se realizaba la maniobra de aproximación al aeropuerto de destino, como consecuencia de haber focalizado la tripulación su atención en la desconexión del piloto automático . A partir del momento en que surgieron dificultades con los mandos de vuelo, la tripulación no realizó los procedimientos estándar de operación establecidos por el explotador de la aeronave."
Accident investigation:
 |
|
Classification:
Distraction in cockpitControlled Flight Into Terrain (CFIT) - Mountain
Sources:
» Comisión de Investigación de Accidentes e Incidentes de Aviación CivilFollow-up / safety actions
Four safety recommendations were issued:
REC 35/05: regarding CRM training for Ibertrans crews
REC 36/05: regarding information dissimination within Ibertrans about the limitations and procedures of the Pitch Trim System Check of the Emb-120 autopilot
REC 37/05: to Embraer, recommending to include the "Pitch Trim Check System" procedure in the Normal Procedures section of the Emb-120 flight manual
REC 38/05: to Embraer, recommending to include a reference about the possibility of an autopilot disconnection in certain casers in the Abnormal and Emergency Procedures section of the Emb-120 flight manual
REC 35/05: regarding CRM training for Ibertrans crews
REC 36/05: regarding information dissimination within Ibertrans about the limitations and procedures of the Pitch Trim System Check of the Emb-120 autopilot
REC 37/05: to Embraer, recommending to include the "Pitch Trim Check System" procedure in the Normal Procedures section of the Emb-120 flight manual
REC 38/05: to Embraer, recommending to include a reference about the possibility of an autopilot disconnection in certain casers in the Abnormal and Emergency Procedures section of the Emb-120 flight manual
Photos
accident date: 14-01-2002
type: Embraer 120RT Brasilia
registration: EC-GTJ
accident date: 14-01-2002
type: Embraer 120RT Brasilia
registration: EC-GTJ
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 Madrid-Barajas Airport to Bilbao Airport as the crow flies is 315 km (197 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from Madrid-Barajas Airport to Bilbao Airport as the crow flies is 315 km (197 miles).
Accident location: Approximate; accuracy within a few kilometers.
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.
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