Narrative:
The Ilyushin 76 departed Macau, carrying 31 tons of telecommunications equipment for a Portuguese telephone company setting up operations in East Timor. Despite numerous attempts, the copilot failed to contact Baucau ATS. The flight navigator then called Baucau Tower. A controller, who was present at Baucau aerodrome at the time, but not on operational duty, advised the flight crew that ATS was not available and that landing would be at the discretion of the flight crew. The pilot in command diverted the aircraft from the published inbound track to the Baucau NDB, and descended the aircraft below the published 10 NM MSA. He continued descending the aircraft through the commencement altitude for the published non-precision instrument approach for runway 14, and through the LSALT.
As the aircraft approached Baucau, the flight crew decided to conduct an overflight of the aerodrome before making a landing approach, and during the overflight, the flight crew realised that the runway was not where they expected it to be. It appeared that the crew did not use the Baucau NDB but used selected data from their instrument approach charts to formulate a user-defined non-precision approach using the onboard global positioning system (GPS). Adding to this, erroneous data on their Jeppesen charts meant the threshold of runway 14 was not where they thought it would be. Had the flight crew followed the non-precision runway 14 NDB approach procedure as published on either the CAD or Jeppesen charts, and not descended below the relevant MDA(H) until visual flight was assured, the position of the runway, as depicted on the Jeppesen charts would have been irrelevant.
During the overflight and the subsequent (first) landing approach, the flight crew realised that the runway was not where they expected it to be as it was depicted on the Jeppesen charts. The pilot in command discontinued the landing approach, and the flight navigator stated that he would apply a 4 km correction to position the aircraft for a second landing approach to where he thought the runway was located. By applying the 4 km correction, the flight navigator was providing the pilot in command with inaccurate data, and resulted in the aircraft being repositioned towards a point about 1.65 km (0.88 NM) northwest of the actual position of the threshold of runway 14. As the aircraft turned on to the final approach heading during the second landing approach, the flight navigator stated that the aircraft was high on the approach profile, based on his assumption of the location of the threshold of runway 14. The pilot in command increased the rate of descent of the aircraft to about 18 m/sec (3,543 fpm), and stated Increased. None of the other crewmembers commented on the high rate of descent, or drew the pilot in commands attention to the fact that the approach was unstabilised at that point.
The flight engineer misinterpreted the pilot in commands statement Increased to be an instruction for him to increase the engine thrust, and he advanced the thrust levers. It took about 2 seconds for the pilot in command to realise that engine thrust had been increased, and he reacted by calling No, I increased vertical speed and reduced the engine thrust. The flight engineers action in increasing engine thrust was a significant distraction to the pilot in command at that stage of the flight, and probably diverted his attention from the primary task of flying the aircraft to restoring the thrust to the proper setting.
At about the same time, the aircraft descended through 162 m, which was the published MDH for a straight-in landing on the runway 14 NDB approach. Neither the pilot in command nor the copilot appeared to notice that the aircraft had descended through the MDH, and it is probable that both were distracted by the flight engineers erroneous action.
The high rate of descent continued unchecked until slightly less than 2 seconds before impact. It is probable that the pilot in command and the copilot were each unaware of the high rate of descent, because neither was monitoring the flight instruments while they were looking ahead of the aircraft and trying to establish visual contact with the ground. The pilot in command applied back elevator to increase the aircraft pitch attitude in response to the co-pilot's urgent expression of concern that impact with terrain seemed almost certain. However, the pilot in command did not simultaneously increase the engine thrust, and it remained unchanged. The airplane impacted the ground. The right wingtip of the aircraft struck a partially constructed house and the aircraft broke up.
SIGNIFICANT FACTORS:
1. The flight crew did not comply the published non-precision instrument approach and/or missed approach procedures at Baucau during flight in instrument meteorological conditions.
2. The flight crew conducted user-defined non-precision instrument approaches to runway 14 at Baucau during flight in instrument meteorological conditions.
3. The pilot in command permitted the aircraft to descend below the MDA(H) published on both the Jeppesen and CAD runway 14 instrument approach charts during flight in instrument meteorological conditions.
4. The flight crew did not recognise the increased likelihood and therefore risk of CFIT.
5. The flight crew did not recognise or treat that risk in a timely manner.
Non-adherence to procedures
Controlled Flight Into Terrain (CFIT) - Ground
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
| Status: | Accident investigation report completed and information captured |
| Date: | Friday 31 January 2003 |
| Time: | 15:21 |
| Type: |  Ilyushin Il-76TD |
| Operator: | Euro Asia Aviation |
| Registration: | RDPL-34141 |
| MSN: | 0053465941 |
| First flight: | 1986 |
| Total airframe hrs: | 2349 |
| Cycles: | 1400 |
| Engines: | 4 Soloviev D-30KP-2 |
| Crew: | Fatalities: 4 / Occupants: 4 |
| Passengers: | Fatalities: 2 / Occupants: 2 |
| Total: | Fatalities: 6 / Occupants: 6 |
| Aircraft damage: | Damaged beyond repair |
| Location: | 2 km (1.3 mls) NNW of Baucau-Cakung Airport (BCH) ( East Timor)
|
| Phase: | Approach (APR) |
| Nature: | Cargo |
| Departure airport: | Macau Airport (MFM/VMMC), Macau |
| Baucau-English Madeira Airport (BCH/WPEC), East Timor |
The Ilyushin 76 departed Macau, carrying 31 tons of telecommunications equipment for a Portuguese telephone company setting up operations in East Timor. Despite numerous attempts, the copilot failed to contact Baucau ATS. The flight navigator then called Baucau Tower. A controller, who was present at Baucau aerodrome at the time, but not on operational duty, advised the flight crew that ATS was not available and that landing would be at the discretion of the flight crew. The pilot in command diverted the aircraft from the published inbound track to the Baucau NDB, and descended the aircraft below the published 10 NM MSA. He continued descending the aircraft through the commencement altitude for the published non-precision instrument approach for runway 14, and through the LSALT.
As the aircraft approached Baucau, the flight crew decided to conduct an overflight of the aerodrome before making a landing approach, and during the overflight, the flight crew realised that the runway was not where they expected it to be. It appeared that the crew did not use the Baucau NDB but used selected data from their instrument approach charts to formulate a user-defined non-precision approach using the onboard global positioning system (GPS). Adding to this, erroneous data on their Jeppesen charts meant the threshold of runway 14 was not where they thought it would be. Had the flight crew followed the non-precision runway 14 NDB approach procedure as published on either the CAD or Jeppesen charts, and not descended below the relevant MDA(H) until visual flight was assured, the position of the runway, as depicted on the Jeppesen charts would have been irrelevant.
During the overflight and the subsequent (first) landing approach, the flight crew realised that the runway was not where they expected it to be as it was depicted on the Jeppesen charts. The pilot in command discontinued the landing approach, and the flight navigator stated that he would apply a 4 km correction to position the aircraft for a second landing approach to where he thought the runway was located. By applying the 4 km correction, the flight navigator was providing the pilot in command with inaccurate data, and resulted in the aircraft being repositioned towards a point about 1.65 km (0.88 NM) northwest of the actual position of the threshold of runway 14. As the aircraft turned on to the final approach heading during the second landing approach, the flight navigator stated that the aircraft was high on the approach profile, based on his assumption of the location of the threshold of runway 14. The pilot in command increased the rate of descent of the aircraft to about 18 m/sec (3,543 fpm), and stated Increased. None of the other crewmembers commented on the high rate of descent, or drew the pilot in commands attention to the fact that the approach was unstabilised at that point.
The flight engineer misinterpreted the pilot in commands statement Increased to be an instruction for him to increase the engine thrust, and he advanced the thrust levers. It took about 2 seconds for the pilot in command to realise that engine thrust had been increased, and he reacted by calling No, I increased vertical speed and reduced the engine thrust. The flight engineers action in increasing engine thrust was a significant distraction to the pilot in command at that stage of the flight, and probably diverted his attention from the primary task of flying the aircraft to restoring the thrust to the proper setting.
At about the same time, the aircraft descended through 162 m, which was the published MDH for a straight-in landing on the runway 14 NDB approach. Neither the pilot in command nor the copilot appeared to notice that the aircraft had descended through the MDH, and it is probable that both were distracted by the flight engineers erroneous action.
The high rate of descent continued unchecked until slightly less than 2 seconds before impact. It is probable that the pilot in command and the copilot were each unaware of the high rate of descent, because neither was monitoring the flight instruments while they were looking ahead of the aircraft and trying to establish visual contact with the ground. The pilot in command applied back elevator to increase the aircraft pitch attitude in response to the co-pilot's urgent expression of concern that impact with terrain seemed almost certain. However, the pilot in command did not simultaneously increase the engine thrust, and it remained unchanged. The airplane impacted the ground. The right wingtip of the aircraft struck a partially constructed house and the aircraft broke up.
Probable Cause:
SIGNIFICANT FACTORS:
1. The flight crew did not comply the published non-precision instrument approach and/or missed approach procedures at Baucau during flight in instrument meteorological conditions.
2. The flight crew conducted user-defined non-precision instrument approaches to runway 14 at Baucau during flight in instrument meteorological conditions.
3. The pilot in command permitted the aircraft to descend below the MDA(H) published on both the Jeppesen and CAD runway 14 instrument approach charts during flight in instrument meteorological conditions.
4. The flight crew did not recognise the increased likelihood and therefore risk of CFIT.
5. The flight crew did not recognise or treat that risk in a timely manner.
Accident investigation:
 |
|
Classification:
Landing after unstabilized approachNon-adherence to procedures
Controlled Flight Into Terrain (CFIT) - Ground
Photos
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
accident date: 31-01-2003
type: Ilyushin Il-76TD
registration: RDPL-34141
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 Macau Airport to Baucau-English Madeira Airport as the crow flies is 3659 km (2287 miles).
Accident location: Exact; as reported in the official accident report.
Distance from Macau Airport to Baucau-English Madeira Airport as the crow flies is 3659 km (2287 miles).
Accident location: Exact; as reported in the official accident report.
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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