Santa Barbara ATR42 near Merida on Feb 21st 2008, went straight into mountain wall

Last Update: April 6, 2020 / 16:52:15 GMT/Zulu time

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Incident Facts

Date of incident
Feb 21, 2008

Classification
Crash

On Apr 4th 2020, after the Venezuelan website for accident investigation came back online after a few years, The Aviation Herald got hold of the final report in Spanish (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Spanish only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).

The JIAAC Venezuela conclude the probable causes of the crash were:

The Attitude and Heading System (AHRS) as device was operational, however the device initialization had not been completed, hence the standard mode remained in a fault condition. This fault condition leaves the radio magnetic indications (RMI) and autopilot inoperative.

The EGPWS was thus also inoperative in its enhanced functions (its information showed in the EFIS system screens), therefore no early warning of impact against the mountain range occured.

The GPS was the only instrument capable of delivering heading information with the accuracy of one degrees. The instrument was located in the lower left of the first officer's instrument panel and was, in addition to the size of the screen, difficult to monitor.

The crew was properly licensed however careless in taking off with the AHRS inoperative in IMC.

The Merida weather station was inoperative.

The control tower did not have a communication recording system.

According to the damage of both engine compressors both engines were delivering power at time of impact.

The JIAAC reported the aircraft had arrived in Merida on Flight S3-517. After the passengers disembarked, the flight crew shut the aircraft down and left the aircraft for the terminal for a rest.

40 minutes prior to scheduled departure of flight 518 the traffic department ordered the boarding of flight 518 to commence, without consulting and release by the flight or cabin crew, neither flight crew nor cabin crew were on board. 4 minutes later the flight attendant arrived at the aircraft. 7 minutes prior to scheduled departure the flight crew entered the cockpit and immediate turned the battery switch to ON skipping the checklists for "Final Cockpit Preparation" and the "Before" checklists. 2 minutes later the crew requested engine start, which was authorized, however, the engines were already running at that time (according to CVR). 2 minutes and 42 seconds after the cockpit crew entered the cockpit tower clears the aircraft to taxi, with an incoming aircraft out at 8nm tower instructed the aircraft to expedite taxiing.

While taxiing the captain (37, ATPL, 5,053 hours total, 3,883 hours o type) recognized they had not aligned the AHRS for not being stationary for 3 minutes and voiced concern, however, decided to reset the AHRS in flight and in the meantime continue with visual operation (according to the manual of the Honeywell AHZ-6000 system in use takeoff in basic flight mode with AHRS inoperative is not recommended).

4 minutes after the flight crew entered the cockpit the flight is cleared for takeoff from runway 24. The captain again emphasizes that the AHRS is in fault mode and they'd realign it in flight (which is not recommended according to the manual by Honeywell).

Following departure the flight climbed in a left turn according to the visual procedures for departure from Merida.

While in the 180 degrees turn the captain reads the after takeoff checklist and reminds the first officer (27, CPL, 2,112 hours total, 602 hours on type) again, that the AHRS is offline, the autopilot is not operative and the first officer needs to fly manually and visually. The aircraft climbed through 10,457 feet MSL and entered cloud, now fully in IMC.

Tower instructs the flight to call "Observation" (as the aircraft was not on its planned departure route), the captain handles the call. Shortly afterwards the GPWS sounds "TERRAIN! TERRAIN! PULL UP! PULL UP!" just when the first officer reported a heading of 073 degrees.

30 seconds after the first alert the GPWS sounded the long alert: "TERRAIN! TERRAIN! PULL UP! PULL UP! PULL UP! PULL UP! PULL UP! PULL UP!" The captain took control of the aircraft, the first officer recognized they were not heading 073 degrees but 318 degrees and were on a wrong course, the first officer also recognized the gravity of the alarm.

Another 15 seconds later the GPWS sounded "TOO LOW GEAR", the first officer again mentions there were on a wrong course of 318 degrees.

Another 6 seconds later the GPWS sounds "TERRAIN! TERRAIN!" and now continuously calls "PULL UP!" The aircraft is being pulled up and turned right, the stick shaker activates. The aircraft impacted "Los Conejos" at an altitude of 12,499 feet MSL at 107 KIAS after 7 minutes and 15 seconds flight time. The aircraft came to rest at an altitude of 12,240 feet at position N8.6772 W71.2114.

All 43 passengers and 3 crew perished in the impact.

The JIAAC analysed that the passengers were already on board of the aircraft when the flight crew entered the cockpit. Due to the resulting pressure the flight crew did not carry out the corresponding checklists before takeoff, which would have made them aware to wait 3 minutes for the AHRS to align. According to the manual the alignment begins as soon as the battery switch is turned ON and takes about 3 minutes during which the aircraft must remain stationary. According to the FDR the time between the battery switch coming on the aircraft startig to move for taxi was 2:42 minutes, which was not enough time for the AHRS to align.

Tower, having another aircraft inbound, instructs the crew to expedite taxiing, which the crew agreed with. The tower subsequently clears the flight onto a heading of 190 direct to "puerto", making use of a route and navigation through "observation alley", that without being approved was persistently being used.

The captain handed controls to the first officer, pilot flying, without consideration that they were flying with the AHRS inoperative. Subsequently, when the aircraft entered cloud the captain continued the flight under those conditions.

Overconfidence in the crew and lack of identification of potential risks contributed that the captain underestimated the risk of takeoff in this unsafe condition.
Incident Facts

Date of incident
Feb 21, 2008

Classification
Crash

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