Accident McDonnell Douglas DC-9-32 YV-23C,
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ASN Wikibase Occurrence # 325819
 

Date:Tuesday 5 March 1991
Time:16:17
Type:Silhouette image of generic DC93 model; specific model in this crash may look slightly different    
McDonnell Douglas DC-9-32
Owner/operator:Linea Aeropostal Venezolana - LAV
Registration: YV-23C
MSN: 47720/846
Year of manufacture:1976
Total airframe hrs:32452 hours
Cycles:50298 flights
Engine model:Pratt & Whitney JT8D-17
Fatalities:Fatalities: 45 / Occupants: 45
Aircraft damage: Destroyed, written off
Category:Accident
Location:27 km NE of Valera -   Venezuela
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Maracaibo-La Chinita International Airport (MAR/SVMC)
Destination airport:Santa Bárbara del Zulia-Las Delicias Airport (STB/SVSZ)
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Aeropostal flight 109 originated in Caracas (CCS), Venezuela on a domestic round trip via Porlamar (PMV), Maracay (MYC), Maracaibo (MAR), Santa Bárbara del Zulia (STB), and Maracaibo.
The flight departed Caracas at 12:05 local time. The first legs of the flight were uneventful. It took off from Maracaibo at 15:58 for the twenty-minute leg to Santa Bárbara del Zulia. The cruising altitude of FL165 was reached at 16:04. The controller at Santa Bárbara del Zulia cleared the flight to descend to 5500 feet, which was confirmed by the crew. The crew then asked if the VOR/DME at the airport was inoperative, which was denied by the air traffic controller.
About 16:15 the descent was arrested. The captain had noticed an erroneous heading selection on the instruments and concluded that they were off course. A climbing right hand turn was flown. The GPWS sounded and a few seconds later, the airplane flew into the side of a fog-shrouded mountain in the La Aguada sector of the páramo Los Torres. Accident elevation was 9912 feet.

PROBABLE CAUSAL FACTORS (translated from original Spanish report):
Collision with mountainous terrain while performing a flight in instrument meteorological conditions under visual flight rules (VFR into IMC) following wrong selection of heading or departure radial which the aircraft followed on its way to the destination airport.

CONTRIBUTING FACTORS
1. The wrong selection of the departure heading from the Maracaibo Airport; the crew selected a course of 153 instead of 193.
2. Lack of supervision of the pilot in command, contributing to flight acts of indiscipline manifested by the following facts:
A) For the modification of flight rules going from visual meteorological conditions (VMC) to instrument flight meteorological conditions (IMC) without appropriate assessment of the geographical position where he was flying.
B) Distraction in the cockpit, the result of the conversation between the captain in command of the aircraft and a third person who was there, a male with aeronautical knowledge specific to a pilot. This situation allowed the error in departure radial selection or error or heading to the airport of destination to go unnoticed while performing the checklist called "Taxi Checklist" .
C) Also influenced by the act of indiscipline, was the fact that an aircraft ADF frequency was tuned to a commercial station throughout the flight, broadcasting a musical program.
3. Unfavourable weather conditions on the flight, present on site at the time of the incident were crucial in its occurrence.
4. The total lack of interaction between the crew (crew coordination).

Sources:

Final Report released by the Ministry of Transport and Communications, Venezuela.

Location

Images:


photo (c) via Werner Fischdick; Caracas-Simón Bolívar International Airport (CCS/SVMI); April 1990

Revision history:

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