Corpflite D228 near Vina del Mar on Sep 9th 2013, impacted ground short of runway
Last Update: March 11, 2020 / 22:46:24 GMT/Zulu time
Incident Facts
Date of incident
Sep 9, 2013
Classification
Crash
Airline
Corpflite
Aircraft Registration
CC-CNW
Aircraft Type
DORNIER 228
ICAO Type Designator
D228
The aircraft was about to pick up passengers at Vina del Mar.
City emergency services reported that traffic near the roundabout at Santa Julia needed to be diverted for rescue and recovery works, a number of residents in Chilquinta were without power due to the cut power lines.
On Nov 20th 2013 Germany's BFU reported in their monthly bullein that the aircraft was on a "ILS-Localizer" approach to runway 05 when it got too low and contacted ground. The BFU, representing the state of manufacture, is participating in the investigation by Chile's Authorities.
Vina del Mar features a runway 05/23 of 5760 feet/1760 meters length, an ILS approach is available for runway 05.
Some time in the past Chile's DGAC released their final report in Spanish only (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 report concludes the probable cause of the crash was:
a controlled flight into terrain (CFIT) one nautical mile southeast of the threshold runway 05, when the aircraft descended below the Minimum Descent Altitude (MDA) published for the ILS X Approach with no glideslope available at Vina del Mar Aerodrome.
Contributing factors were:
- non-application of concepts of Cockpit Resource Management (CRM)
- no use of checklists
- no briefings of the maneouvers to be executed
- loss of situational awareness by the crew
- no sterile cockpit during the approach
- pilot complacency an overconfidence
- unstabilized approach
- lack and/or non-use of equipment and systems in support of the flight
The DGAC reported the captain (66, CPL (!), 15,537 hours total, 12,431 hours on type) was pilot flying, the first officer (58, ATPL, 10,777 hours total, hours on type not recorded) was pilot monitoring.
The flight crew participated in a briefing for the mission together with the crew of another flight to Vina del Mar at the company facilities in Santiago de Chile. The crews were handed the current NOTAMs (amongst other briefing materials) which indicated the ILS at Vina del Mar had no glideslope operative, thus only a non-precision instrument approach was possible (LOC approach runway 05).
The crew was assigned to operate from Santiago to Los Pelambres, further to Vina del Mar, back to Los Pelambres and Santiago. The crew delivered the first passengers from Santiago to Los Pelambros without incident. The flight crews of the two flights met in Los Pelambros again and discussed the weather situation at Vina del Mar.
The accident flight departed first for Vina del Mar with the second company aircraft following. On approach to Vina del Mar the crew requested the LOC approach to runway 05 acknowledging the glideslope was unserviceable. At the time of the approach the weather conditions were above the minima for the approach.
When the crew contacted Vina del Mar's tower, the first officer requested an ILS approach to runway 05, the controller advised that the glideslope was unserviceable. The crew subsequently briefly discussed the limitations of the LOC approach and discussed the MDA. The crew set the MDA to 1000 feet MSL (as published). The first officer engages in a discussion unrelated to the flight until the captain interrupted him " let's descend to 3500 feet", then the first officer continued the theme, the captain again interrupted "let's descend to 3000 feet now". The aircraft positioned for the base turn using the VOR, the first officer again engaged in the previous theme. The crew turns onto base and final, selects the gear down and applies the flaps, the first officer returned to his theme again, the captain interrupts asking the first officer "Localizer is 049 degrees", which the first officer affirmed and returned to his talking theme.
The captain asks for the DME and altitude of the final approach fix, the first officer does not provide an answer but instead reports "according to GPS we are doing fine". A short time later the first officer states they should start their descent at 4.1nm out to 1000 feet MSL (MDA) and should maintain 1000 feet MSL.
The first officer subsequently recommended to increase the sink rate, the captain replied he had already increased to 1200 fpm. The first officer communicates with tower indicating they were at 3 miles out, three greens. Tower cleared the flight to land on runway 05 with winds at 300 degrees at 8 knots.
The first officer suggests to fly a little bit right, the captain affirms they were established, then the first officer advises they were at MDA and remarks they were descending below MDA.
About three seconds later, about one nautical mile ahead of the runway 05 threshold at position S32.965 W71.5016, the right horizontal stabilizer of the aircraft struck a pine tree of 20 meters height, subsequently the aircraft collided with a medium voltage cable and hit the ground. The aircraft came to a stop practically aligned with the center line of the runway. Both flight crew died on the scene of the crash, the aircraft was destroyed as well as parts of the perimeter fence of Vina del Mar aerodrome, a pole of the medium voltage line and the cable.
Both FDR and CVR were recovered and sent to the NTSB for read out.
With the exception of the glideslope transmitter of the ILS runway 05 all navigation equipment was working normally including localizer, LOC/DME, VOR and VOR/DME.
The DGAC analysed that the aircraft was airworthy and within all limitations including mass and balance. The operator demonstrated to have been in compliance with all maintenance regulations.
At the time of the approach the visibility was 2000 meters horizontally, the cloud base at 600 feet AGL (1091 feet MSL) and thus was above the required minima, 1600 meters horizontal visibility. However, a rapid deterioration of weather conditions had occurred, confirmed by a helicopter pilot 22 minutes after the accident who reported the cloud base at about 100 to 200 feet AGL and horizontal visibility about 1000 meters.
Ground facilities did not contribute to the accident, the glideslope was unserviceable and properly brought to the attention of flight crews.
The DGAC analysed that both crew were quite familiar with the operations at Vina del Mar, as they flew regularly to the aerodrome. This high level of experience at the aerodrome helped the confidence of the crew leading to overconfidence. The crew listened to music during the initial approach, the commander focussed his attemption onto an ambulance aircraft operating into Vina del Mar in the early stages of the approach, the lack of an approach briefing, the attempts by the captain to use his mobile phone twice (probably to contact the ambulance aircraft), the tone and theme of the conversations between the crew as well as the fact that neither pilot had his seat belts securely fastened on impact demonstrate complacency by the crew.
The DGAC analysed the roles of the two pilots based on the CVR and their conversations as if the first officer acted like a flight instructor resulting in a much more difficult hierarchy impairing cockpit resource management. The DGAC wrote: "Despite being highly experienced and well qualified pilots they failed to complement each other and did not efficiently manage the resources available to them. Thus, the interaction between them during this flight meets the characteristics of an anarchic cockpit."
According to the approach chart the recommended rate of descent was 677 fpm between the FAF (Final Approach Fix) and the MAP (Missed Approach Point), however, the crew had adopted 1200 fpm, which also exceeds the criteria for stabilized approaches limiting the rate of descent to 1000 fpm. The crew thus performed an unstabilized approach, and despite some attempts to correct the trajectory did not stop the descent at the MDA. As result the aircraft contacted the pine tree located about 0.48nm ahead of the position they should have reached 1000 feet MSL at.
Metars:
SCVM 091700Z 34012KT 1500 BR OVC005 14/13 Q1020=
SCVM 091600Z 34013KT 0800 FG OVC002 13/12 Q1019=
SCVM 091500Z /////KT 0400 FG VV/// 13/12 Q1018=
SCVM 091400Z /////KT 0600 FG OVC002 13/12 Q1017=
SCVM 091300Z /////KT 0800 FG OVC005 13/09 Q1014=
SCVM 091200Z 30007KT 8000 SCT010 BKN090 13/09 Q1014=
SCVM 091100Z 26004KT 9999 SCT090 13/06 Q1013=
SCVM 091000Z 00000KT 9999 FEW090 14/08 Q1012=
SCVM 090900Z 15004KT 9999 FEW090 15/07 Q1011=
SCVM 090800Z 23005KT 9999 SCT090 16/09 Q1011=
Related NOTAMs:
B0739/13 - GLIDE SLOPE RWY05 FREQ 330.2 MHZ U/S AFFECTS MIN APCH ILS EXRAY AND ILS YANKIE. 05 SEP 20:23 2013 UNTIL 13 SEP 21:30 2013. CREATED: 05 SEP 20:23 2013
B0701/13 - ILS/LLZ RWY05 FREQ 110.7 MHZ/CH44X OPRG WO SRY EQPT. 28 AUG 21:53 2013 UNTIL 27 SEP 22:20 2013. CREATED: 28 AUG 21:53 2013
B0700/13 - L SAL FREQ 390 KHZ U/S NOT AVBL AFFECTS IAC-1 IAC-4 IFR APCH. 28 AUG 21:07 2013 UNTIL 27 SEP 22:20 2013. CREATED: 28 AUG 21:07 2013
Incident Facts
Date of incident
Sep 9, 2013
Classification
Crash
Airline
Corpflite
Aircraft Registration
CC-CNW
Aircraft Type
DORNIER 228
ICAO Type Designator
D228
This article is published under license from Avherald.com. © of text by Avherald.com.
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