Narrative:A Cessna 500 Citation I corporate jet was destroyed when it crashed near Santiago de Compostela Airport (SCQ), Spain. Both pilots were killed in the accident.
They had flown a transplant organ to Porto that night and were returning to Santiago de Compostela, leaving Oviedo Airport at 05:45.
Ten minutes later, the crew contacted approach control and was then authorized to make the ILS approach to runway 17 at Santiago de Compostela. The visibility at the airport was suitable for landing. At 06:15 hours the crew contacted Tower Control and was cleared to land. Two minutes later the aircraft impacted wooded terrain, 200 meters before the VOR of Santiago, about 1 mile before the threshold of runway 17.
Probable Cause:
Causes
The ultimate cause of the accident could not be determined. In light of the hypothesis considered in the analysis, the most likely scenario is that the crew made a non-standard precision approach in manual based primarily on distances. The ILS frequency set incorrectly in the first officer's equipment and the faulty position indicated on the DME switch would have resulted in the distance being shown on the captain's HSI as corresponding to the VOR and not to the runway threshold. The crew shortened the approach maneuver and proceeded to a point by which the aircraft should already have been established on the localizer, thus increasing the crew's workload. The crew then probably lost visual contact with the ground when the aircraft entered a fog bank in the valleys near the airport and did not realize they were making an approach to the VOR and not to the runway.
The contributing factors were:
- The lack of operational procedures of an aircraft authorized to be operated by a single pilot operated by a crew with two members.
- The overall condition of the aircraft and the instruments and the crew's mistrust of the onboard instruments.
- The fatigue built up over the course of working at a time when they should have been sleeping after an unplanned duty period.
- The concern with having to divert to the alternate without sufficient fuel combined with the complacency arising from finally reaching their destination.
Accident investigation:
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Investigating agency: | CIAIAC Spain |
Status: | Investigation completed |
Duration: | 2 years and 11 months | Accident number: | A-029/2012 | Download report: | Final report
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Classification:
Insufficient rest / fatigue
Cause undetermined
Controlled Flight Into Terrain (CFIT) - Ground
Sources:
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SKYbrary
METAR Weather report:
04:30 UTC / 06:30 local time:
LEST 020430Z 00000KT 5000 R17/0450V1700U BR FEW006 13/13 Q1019 NOSIG04:30 UTC: Winds calm; Visibility: 5000 m; mist, few clouds at 600 feet AGL; Runway Visual Range along Runway 17 is varying between 450 m and 1700 m and is improving; Temperature and Dew point: 13°C; Pressure: 1019 mb
Follow-up / safety actions
CIAIAC issued 6 Safety Recommendations
Issued: 24-JUN-2015 | To: Airnor | REC 09/15 |
It is recommended that AIRNOR develop a specific plan that would ensure that the crews annotate all the discrepancies of the aircraft in the TLB at the moment they are detected. |
Issued: 24-JUN-2015 | To: AESA | REC 10/15 |
It is recommended that AESA revise its supervisory policies (for both operations and aircraft (ACAM/SAFA)) to establish criteria and define procedures for inspections in line with the objectives that are actually being pursued in terms of safety standards. |
Issued: 24-JUN-2015 | To: Airnor | REC 11/15 |
It is recommended that AIRNOR establish the operational procedures required to operate in each of its aircraft based on the equipment specific to each, and on clear and common criteria for weather conditions, fuel planning and stabilized approaches. |
Issued: 24-JUN-2015 | To: AESA | REC 12/15 |
It is recommended that AESA take the initiative so as to establish as mandatory, following international orientations from ICAO Annex 10, for all operators the registration of the data from ELT. |
Issued: 24-JUN-2015 | To: ENAIRE | REC 13/15 |
It is recommended that ENAIRE establish the procedures needed to remind control personnel during refresher training of the emergency phase and of the obligation to monitor the operation of aircraft operating in and around the airport. |
Issued: 24-JUN-2015 | To: DGAC Spain | REC 33/15 |
It is recommended that DGAC, at the initiative of AESA, establish as mandatory, following international orientations from ICAO Annex 10, for all operators the registration of the data from ELT. |
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Photos
accident date:
02-08-2012type: Cessna 500 Citation I
registration: EC-IBA
accident date:
02-08-2012type: Cessna 500 Citation I
registration: EC-IBA
accident date:
02-08-2012type: Cessna 500 Citation I
registration: EC-IBA
accident date:
02-08-2012type: Cessna 500 Citation I
registration: EC-IBA
accident date:
02-08-2012type: Cessna 500 Citation I
registration: EC-IBA
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 Oviedo/Aviles-Asturias Airport to Santiago de Compostela Airport as the crow flies is 205 km (128 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.