ASN Aircraft accident Boeing 727-230 HC-BSU Bogotá-Eldorado Airport (BOG)

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Status:	Accident investigation report completed and information captured
Date:	Monday 20 April 1998
Time:	16:45
Type:	Boeing 727-230
Operator:	TAME Ecuador
On behalf of:	Air France
Registration:	HC-BSU
MSN:	21622/1431
First flight:	1979-01-03 (19 years 4 months)
Total airframe hrs:	34586
Cycles:	26475
Engines:	3 Pratt & Whitney JT8D-15
Crew:	Fatalities: 10 / Occupants: 10
Passengers:	Fatalities: 43 / Occupants: 43
Total:	Fatalities: 53 / Occupants: 53
Aircraft damage:	Destroyed
Aircraft fate:	Written off (damaged beyond repair)
Location:	10 km (6.3 mls) SW of Bogotá-Eldorado Airport (BOG) ( Colombia)
Crash site elevation:	3054 m (10020 feet) amsl
Phase:	En route (ENR)
Nature:	International Scheduled Passenger
Departure airport:	Bogotá-Eldorado Airport (BOG/SKBO), Colombia
Destination airport:	Quito-Mariscal Sucre Airport (UIO/SEQU), Ecuador
Flightnumber:	AF422

Narrative:
A Boeing 727 passenger plane, HC-BSU, was destroyed when it flew into the side of a mountain near Bogotá, Colombia. All 53 on board were killed.
The airplane had been wet-leased by Air France from TAME Ecuador, a commercial division of the Ecuadorian Air Force. The flight crew regularly flew the Bogota-Quito-Bogota route as the final leg of Air France's scheduled flight 422 from Paris. Air France operated Airbus A340s on the Paris-Bogota leg, but demand on the Quito leg was too weak for use of such a high-capacity transport.
Flight 422 took off from runway 13 at Bogotá after being cleared for a 'Girardot 1' departure. This departure consist of continuing on runway heading for 2 miles after takeoff, followed by a 90-degree right turn over the 'Romeo' beacon. The flight didn't make the right turn and continued straight ahead.
At 16:47 the aircraft crashed into the side of the 3.100 m (10.170 ft) high Cerro el Cable mountain, 150 feet below the summit. This is 500 m (1640 ft) above airfield elevation).
Rain showers were in the area at the time with a broken ceiling at 2300 feet and towering cumulus clouds. Temperature was 18deg. C and winds were from 270 deg at 5kts.
On August 27, 1973 a Lockheed L-188A Electra (HK-777, Aerovias Condor) had also crashed into the Cerro el Cable after takeoff from Bogotá.

Probable Cause:

PROBABLE CAUSE (translated from original Spanish report):
The loss of situational awareness by the crew, which led to the failure to comply with the GIR 1 departure, deviating from the procedure to maintain runway heading after takeoff until it collided with terrain.

Accident investigation:

Investigating agency:	Aerocivil
Status:	Investigation completed
Accident number:	Final report
Download report:	Final report

Classification:

Controlled Flight Into Terrain (CFIT) - Mountain

Sources:

» Aviation Week & Space Technology 27.04.1998 (45)
» ICAO Adrep Summary 3/98 (#14)

Follow-up / safety actions

Aerocivil issued 21 Safety Recommendations

Issued: --	To: TAME Ecuador	HC-BSU (1)
Crear sus propios departamentos independientes de CRM, Seguridad Aérea, Entrenamiento de vuelo y Flight Standards, que emitan normas y políticas tendientes a mejorar la seguridad de las operaciones aéreas y que sean hechos cumplidos por dicha empresa.
Issued: --	To: TAME Ecuador	HC-BSU (10)
Asegurar que las tripulaciones se clnan a los procedimientos operacionales estándar con o sin supervisión como norma general de operación.
Issued: --	To: TAME Ecuador	HC-BSU (11)
Desarrollar e implementar un programa de CRM formal para todo el personal involucrado en las operaciones de vuelo.
Issued: --	To: TAME Ecuador	HC-BSU (12)
Equipar su flota de aeronaves con el equipo EGPWS (Enhanced Ground Proximily Warning System).
Issued: --	To: TAME Ecuador	HC-BSU (13)
Equipar la flota de aeronaves con equipos Registradores de Datos de Vuelo (Flight Data Recorder), de acuerdo a lo establecido por la OACI.
Issued: --	To: DGAC Ecuador	HC-BSU (14)
Asegurar que la aerolínea TAME cumpla con los requerimientos OACI respecto a los equipos grabadores de datos de vuelo.
Issued: --	To: DGAC Ecuador	HC-BSU (15)
Crear normas que exijan a los inspectores de la misma autoridad que sean calificados en el tipo de avión en el cual estén efectuando un chequeo.
Issued: --	To: DGAC Ecuador	HC-BSU (16)
Exigir a las entidades que proveen entrenamiento a la empresa TAME, en este caso F.S.I. que elaboren y guarden récords o historia del rendimiento y progreso diario de los tripulantes que efectúen entrenamiento en estos centros de instrucción.
Issued: --	To: Aerocivil	HC-BSU (17)
Establecer una reglamentación que asegure que los horarios de trabajo de ... los controladores de tránsito aéreo permitan periodos de descanso adecuados.
Issued: --	To: ICAO	HC-BSU (18)
Asegurar que todas las aerolineas que contraten a otras para volar bajo su nombre, dispongan de una supervisión efectiva a la aerolínea contratada para que estas operen bajo las normas de la compañia contratante.
Issued: --	To: ICAO	HC-BSU (19)
Requerir que las cartas de navegación de baja altura y área terminal muestren gráficamente las características del terreno en una forma facil de interpretar.
Issued: --	To: TAME Ecuador	HC-BSU (2)
Supervisar directamente los entrenamientos de las tripulaciones, orientados a sus operaciones aéreas con sus propios instructores.
Issued: --	To: ICAO	HC-BSU (20)
Crear normas especificas sobre la implementación de dias libres a las tripulaciones en vez de referirse a periodos de descanso .
Issued: --	To: Air France	HC-BSU (21)
Ejercer una estrecha vigilancia a las compamas contratadas para que sigan los lineamentos y conductas expuestos por la empresa contratante.
Issued: --	To: TAME Ecuador	HC-BSU (3)
Efectuar chequeos de rutas a cada aeropuerto con sus propios chequeadores de rutas.
Issued: --	To: TAME Ecuador	HC-BSU (4)
Incluir sesiones de L.O.F.T en sus entrenamientos.
Issued: --	To: TAME Ecuador	HC-BSU (5)
Instruir a los tripulantes en la filosofía de las prácticas de seguridad en las operaciones aéreas.
Issued: --	To: TAME Ecuador	HC-BSU (6)
Adoctrinar a las tripulaciones sobre las práclicas de los briefings operacionales y la obligatoriedad de confinnar las listas de comprobación.
Issued: --	To: TAME Ecuador	HC-BSU (7)
Hacer énfasis a las tripulaciones en la necesidad de seguir estrictamente los procedimientos de salida.
Issued: --	To: TAME Ecuador	HC-BSU (8)
Establecer un mecanismo para asegurar que las tripulaciones cumplan con altos estándares operacionales.
Issued: --	To: TAME Ecuador	HC-BSU (9)
Instruir a las tripulaciones a través de talleres de CRM para lograr el desarrollo de una alta conciencia situacional durante la ejecución de las operaciones aéreas.

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Photos

accident date: 20-04-1998
type: Boeing 727-230
registration: D-ABKS

Aircraft history

date	registration	operator	remarks
03 JAN 1979	D-ABKS	Lufthansa
09 SEP 1993	HC-BSU	TAME Ecuador

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 Bogotá-Eldorado Airport to Quito-Mariscal Sucre Airport as the crow flies is 719 km (450 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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