LAM E190 over Botswana/Namibia on Nov 29th 2013, captain intentionally crashed aircraft

Last Update: April 16, 2016 / 10:27:47 GMT/Zulu time

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Incident Facts

Date of incident
Nov 29, 2013

Classification
Accident

Aircraft Registration
C9-EMC

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

On Apr 15th 2016 Namibia's Directorate of Aircraft Accident Investigations (DAAI) released their final report concluding the probable cause of the crash was:

The inputs to the auto flight systems by the person believed to be the Captain, who remained alone on the flight deck when the person believed to be the co-pilot requested to go to the lavatory, caused the aircraft to departure from cruise flight to a sustained controlled descent and subsequent collision with the terrain.

Contributing factors

The non-compliance to company procedures that resulted in a sole crew member occupying the flight compartment.

Editorial note: a few days after the crash The Aviation Herald received information from two different and independent sources that the captain had suffered a row of serious blows of fate, the two sources also supplied other detailed information,small fractions of such information also appeared as rumours in a few pilot discussion fora. Rather than publishing the information, which despite two independent sources was deemed unverified, The Aviation Herald forwarded the information to Namibia's investigator in charge. Large parts, but not all, of that information forwarded were confirmed by the final report. Both sources, in addition, had reported that the captain had attempted to be relieved from flying duties on the day of the crash, however, had been turned down by LAM's chief of staff. This information was not mentioned and thus not verified in the final report.

The DAAI wrote in their final report:

The Investigation team also discovered through the interview that the captain went through numerous life experiences ranging from:

a) The separation from the first wife on which the divorce process had not been dissolved to almost (10) years after separation.

b) The death of a son who passed away in a car accident on a suspected suicide on the 21st of November 2012.

c) The captain was reported as not to have attended his son’s funeral.

d) The captain’s youngest daughter underwent heart surgery in one of the hospitals in South Africa not long time ago.

The DAAI reported the captain (49, ATPL, 9,052 hours total, 2,519 hours on type) was pilot monitoring, the first officer (24, CPL, 1,183 hours total, 101 hours on type) was pilot flying. About 1:50 hours into the flight the first officer handed the controls to the captain and left the cockpit for a toilet break.

The DAAI reported that even after the first Ground Proximity Warning activated recovery of the aircraft would have been possible despite the high vertical speed, at times in excess of 10,000 fpm, as shown on full flight simulators.

The DAAI stated: "Due to high rate of impact forces the accident was not survivable."

The DAAI reported that the remains of all occupants were successfully identified. The remains of both pilots were examined by blood alcohol and toxicological analysis. The DAAI wrote: "None was found given the degree of fragmentation and degradation discussed supra."

The DAAI reported the ELT did not function, no ELT signal was received. The exact cause could not be clarified. The DAAI wrote however: "There is a need to increase their affectivity even on a high energy crash. Technology exist such as in mobile phones and satellite phones that enable transmission through an integral antenna as opposed to the remote fuselage fixed antenna that requires a routing to the unit."

The DAAI reported that great care was taken to recover all debris, clean the crash site and restore it natural environment as much as possible.

The DAAI reported that the weather in the area had been clear with nearly unrestricted visibility and was no factor into the crash.

The DAAI analysed cockpit conversations:

Most of the conversation in the cockpit for the first one hour and fifty minutes of the flight was dominated by general discussion about the country’s politics and social activities. There was a cordial if not pleasant conversation between the two crew members in the cockpit, at no point was there a hint of any un-procedural activities or other deviation.

After 1hour 50 minutes into the flight the First Officer stated he had to go to the toilet and asked the captain if he had controls to which he responded “no problem” and thereafter sounds similar to door unlock jingle are heard and then immediately after, the electromechanical door latch are closing.

From this time there was no other intra-cockpit conversation recorded on the CVR indicating that the Captain remained alone in the cockpit which is not in line with the company procedures.

...

At around 1:56:46 into the flight, sounds were heard of someone trying to open the door. Spoiler panels were then commanded open and remained in this condition for the rest of descent.

The DAAI analysed that examination of the debris, in particular engine blades, showed a high energy impact, the engines were at high rotational speed. This is consistent with the flight data recorders which showed the engines continued to operate at about 40% N1 throughout the descent during the last 6 minutes of flight.

The DAAI released 6 safety recommendations as result of the investigation:

To Mozambique's Civil Aviation Authority:

DAAI recommends that Mozambique Civil Aviation Authority should come up with a mechanism to ensure that the procedure of two people in the flight deck is adhered to at all times as laid out in LAM’s Manual of Flight Operation Chapter 10.1.4, Page 5 of 36, Edition 3 Revision 8, (Absence from Flight Deck).

All remaining safety recommendations to ICAO:

DAAI recommends that ICAO should establish a working group that should look into the operation and the threat management emanating from both side of the cockpit door.

DAAI recommends that ICAO should establish standards that implement recommendations of the working group, formed under safety recommendations number 002/2015 LAM to suitably avert the locking out of the cockpit of authorized crew members.

DAAI recommends that ICAO should establish a working group to review the installation of visual recording inside and outside the cockpit that should provide information on who was in the cabin, who exactly was controlling the plane at the time of the accident and even where their hands were in relation to the plane’s controls.

DAAI recommends that ICAO should expedite the implementation of international requirements on global tracking of airline flights providing early warning of, and response to, abnormal flight behavior information to ensure that search and rescue services, recovery and accident investigation activities are conducted timely.

DAAI recommends that ICAO working group (Global Tracking 2014-WP/6) speeds up the research and implementation of aircraft tracking and localization other than ELT system.
Incident Facts

Date of incident
Nov 29, 2013

Classification
Accident

Aircraft Registration
C9-EMC

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

This article is published under license from Avherald.com. © of text by Avherald.com.
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