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Boeing 727-21, HK-1716, accident at El Espartillo, Cucuta, Colombia on 17 March 1988.

Report released by Civil Aviation Department, Colombia.


Prepared by Harro Ranter

Source: Aircraft Accident Digest (ICAO Circular 260-AN/154) p.12-26.


INDEX


1.0 OCCURRENCE INFORMATION
1.1 History of the flight
1.2 Injuries to persons
1.3 Damage to aircraft
1.4 Other damage
1.5 Personnel information
1.6 Aircraft information
1.7 Meteorological information
1.8 Aids to navigation
1.9 Communications
1.10 Aerodrome information
1.11 Flight recorders
1.12 Wreckage and impact information
1.13 Medical and pathological information
1.14 Fire
1.15 Survival
1.16 Tests and investigation
1.17 Additional information
1.18 New investigative techniques
2.0 ANALYSIS
2. 1 Fitness of the crew
2.1.1 Fitness of the air traffic controllers
2.2 Airworthiness status of HK-1716
3. CONCLUSIONS
4.0 RECOMMENDATIONS

1.0 OCCURRENCE INFORMATION

1.1 History of the flight

On 17 March 1988, HK-1716 operated by AVIANCA S.A. took off from Palonegro Airport, Bucaramanga, on Flight 0410 to Cucuta, Cartagena and Barranquilla. HK-3133, which should have been used on that flight, had been replaced in Bogota by HK-1716 for maintenance reasons and the flight left Bucaramanga for Cucuta at 12:09 local time, 2 hr 30 min behind schedule. The pilot in command of the aircraft was Capt. PTL-1036 (dec.); he was accompanied by Capt. PC-4570 (dec.) and flight engineer IDV-256 (dec.). The flight attendants were ASA-2410, ASA-3014 and ASA-2407 (dec.).

The flight left Bucaramanga with 142 persons on board and 17,000 pounds of fuel. According to Palonegro Tower, the take-off was uneventful and at 12:16 local time, the flight reported level at 17,000 ft at ARENA intersection and then changed frequency to 119.9 (Cucuta Approach).

The aircraft landed at Cucuta at 12:28 local time [the flight engineer reported the arrival time as three five (35)], disembarked 71/5 pax and then bearded 76/7 pax (figures deduced from the passenger list). At 13:06:56 local time, the pilot requested clearance to initiate the flight to Cartagena ("To Cartagena, [requesting] clearance to start"). At 13:07:58 local time, the Tower informed him that there would be a 10-minute delay before taxiing (TW "You have a ten minute delay before taxiing"), and when asked "Could you tell me why?" he responded that he had three aircraft on the VOR on instrument procedures (TW "Traffic three aircraft on the VOR for instrument procedures"). The crew immediately requested clearance for a climb on course (C1 "Why not clear us to climb on course to avoid delaying this flight further? We're pretty far behind") and the tower granted their request at 13:08:34 local time (TW "OK, cleared for engine start, climb on course VMC, report ready to taxi, temperature 28°/ C2: OK/ TW: Correction, temperature 29°); a few seconds later the crew reported ready to taxi and at 13:10:00 local time the tower instructed them to taxi to position on runway 33 ~W "Avianca 1716 taxi to position runway 33, 360° 15 kt, time is 18:10, taxi Brave, QNH 3002"). The aircraft taxied to that position and at 13:12:08 local time the tower reported, "Cleared to Cartagena via Uniform Whisky 19, Whisky 7, Whisky 10, climb and maintain two six zero after take-off, climb on course VMC, QNH ......, correction transponder Alpha 2216". Take-off clearance was issued at 13: 13:14 local time (TW "Cleared for take-off, wind is 015° 10 kt/ C2: 1716") and the aircraft initiated take-off at 13:13:19 local time, completing it at 13:14:09 local time, at which time the pilot said, "Taking off and proceeding as cleared, Avianca 1716". At this point, the aircraft had 143 persons on board and 20,000 pounds of fuel. Accotding to data obtained later, the initial climb path followed the extended runway centre line to the inner marker, at which point the aircraft entered a left turn, reaching headings of 319" in the first minute, 291.6° in the second minute, 310.6° in the third minute, 317° for another 17 seconds, and finally 310.1° in the last 8 seconds.

At 13:15:44 local time, the pilot informed his counterpart on HK-727 that they were turning left: "C1: Pablo, we're turning left here, towards La Cuchilla", and at the end of the CVR tape, at 13:17:44, the pilot said to the copilot, "In any case, start turning right." At 13: 17:46 local time, the aircraft struck the peak of El Espartillo (located in the municipality of El Zulia, district of Norte de Santander, coordinates 08° 05' N 72° 41' 30" W) at an elevation of 6,343 feet, and was completely destroyed.

All 143 persons on board perished as a result of the impact and explosion. There was no fire. It was daylight, with thick fog in the area of the accident. The only witness to the crash stated that the aircraft had passed over his house at a very low height above ground.

1.2 Injuries to persons

INJURIES CREW PASSENGERSOTHERS
Fatal 6-1129/7--
Serious------
Minor/none ------

1.3 Damage to aircraft

The aircraft was completely destroyed. All parts and components were damaged as a result of the impact with the rocks and the subsequent explosion; there was no generalized fire; some parts were charred by small isolated fires.

1.4 Other damage

An area of 1,200 square metres of forest on El Espartillo was destroyed.

1.5 Personnel information

Pilot-in-command
Name
Nationality Colombian
35
LicencesHe obtained licence APA-2793 on 18 August 1971 to begin private pilot training at the Escuela Aerocentro. On 24 April 1972 he was issued PC-1772 with authorization to operate single-engined land aeroplanes up to 5 700 kg. He obtained co-pilot ratings for the DC-3 on 3 October 1972, the DC-4 on 11 May 1973, the B-727 on 20 February 1976 and the B-72O/B-707 in June 1978. On 1 December 1980, he was issued PTL-1036 with an endorsement to act as pilot-in-command of the B-727.
Medical certificate No. 11.356, valid until 2 August 1988
Last check -- aircraft type He received three days (15 hours) of recurrent training on 10- 12 August 1987, and was assessed as O.K. in all areas; he had four hours of B-727-200 simulator training on 16-17 August 1987 with instructor and was rated "satisfactory" with the comment: "Capt. knows and flies the aircraft very well. Above average pilot. Check satisfactory." Valid up to 16 August 1988.
Equipment flown as pilot-in- command PA-18, DC-3, with weights up to 5,670 kg, and B-727.
Total time as pilot-in-command 5,722:27
Total time on type 9,727:35, of which 4,050 was as co-pilot of the B-727
Flight time last 90, 30 and 4 days 219:53, 73:25, 13:15 hours, respectively
Other information

His last vacation was from 15 November to 15 December 1987.

Comment following flight simulator check on 10 November 1983: "Had difficulty with flight director tracking on ILS, but corrected well. Satisfactory job.

Comment following CUC-SMR-BAQ-CUC line check attached to the foregoing: "Disciplined. Good pilot." Comment on annual simulator check carried out on 16 October 1985: "Satisfactory periodic simulator check.

His last period of continuous rest was on 12 and 13 March of the current year.

Under Administrative Order No. 02950 of 18 March 1987 from the Department of Civil Aviation Administration, he was cited for violation of the Manual of Aeronautical Regulations, para. 4.2.8.3 for exceeding the total annual flight time permitted in 1986.

Co-pilot

Name
Nationality Colombian
Age23
LicencesStudent pilot licence no. 7780 was issued on 21 December 1984 with the following limitations and privileges: Aerocentro received training as a commercial pilot valid for two years. On 16 September 1985 Escuela Aerocentro de Colombia requested authorization from the Department to conduct the final flight check of the course, a check that was conducted by Capt. , IVA-404, whose final evaluation was: "All ground material approved without difficulty. No difficulty in flight either; good aptitude and interest. Can be considered within the general average as a student. Passed final checks satisfactorily. On this basis, the Department of Civil Aviation Administration issued Commercial Pilot Licence no. 4570 to him on 16 October 1985 with the following limitations: "Single-engined land aeroplanes up to 5 670 kg. On 19 February 1986 he began B-727 ground school as a co- pilot with Avianca. The course lasted 59 days and totalled 295 hours. He flew 60 hours as an observer, received 22 hours of simulator training (with a 2-hour check ride) and 1 hour 15 minutes Aight training, with a 30-minute final check in the aeroplane. He completed the course satisfactorily and received his rating as co-pilot on the B-727. On 27 August 1986, the Department re-issued Commercial Pilot Licence No. PC-4570 with an endorsement qualifying him as a B-727 co-pilot.
Medical certificate No. 19444, valid until 3 June 1988.
Last check -- aircraft typeReceived 3 days of recurrent training on the machine from 10 to 12 August 1987, for a total of 15 hours, and was assessed OK in all areas. Between 22 and 23 August 1987, he trained on the B-727-200 simulator with Instructor for 4 hours, and was assessed Satisfactory with the comment:. "Capt. check ride was satisfactory; he was advised not to try to rush thing. He showed himself to be studious and serious about his profession.
Aircraft down as pilot-in-command PA-28 (pilot)
Total flight time The only time recorded is 205:24 hours flight time and 30:06 hours in the Link trainer.
Flight experience on type 340:22 hours
Flight time last 90, 30 and 3 days 147:35, 47:10 and 01:30 hours respectively
Other information

All the documents concerning Capt. were reviewed, and no reference to incidents or accidents was found.

According to Avianca records, he was off duty on 13, 14, 15 and 16 March.

Flight engineer
Name
Nationality Colombian
Age
LicencesOn 28 November 1969 he was issued Aeroplane technician's licence TAV-1171, with the following limitations and privileges: Single and twin piston-engined aeroplanes up to 3,500 kg, C-45, DC-3, DC-4, and power plant technician's licence TPM-1543 for piston engines up to 1400 HP. According to Colombian Air Force records, having met the Department's requirements on 25 August 1976, he was issued Flight Engineer's Licence IDV-256 for the C-130, and on 24 November 1980 Licence IDV-256 was re-issued with an added endorsement for the B-727.
Medical certificate No. 13657, valid until 28 July 1988.
Last check - aircraft type He received recurrent training on the B-727 from 21 to 23 April 1987, a three-day course consisting of 15 hours and given by instructor : rated OK. On 23 and 24 May 1987 he received 4 hours of simulator training supervised by , IDV-029, the result being: "Practised and clarified asymmetry/split flap landing procedure. Practised and darified fuel dumping procedure. General performance and training satisfactory.
Aircraft flown as pilot-in- command Not applicable
Total flight timeAccording to Certificate no. 148 issued on 27 June 1983 by the Department of Civil Aviation Administration, he had logged a total of 1,765 hours 35 minutes flight time as Engineer.
Total flight experience on type5,687:50 hours
Total Right time last 90, 30 and 3 days732:15, 85:00, 16:45 hours, respectively
Other information

A review of the documents concerning the flight engineer established that he had come from the FAC, an institution in which he worked for about 15 years as an aircraft technician specialized in the maintenance of C-45, C-47, C-54 and C-130 aeroplanes; he also held an FAA flight engineer's licence for turbo-jet aeroplanes.

Administrative Order no. 2955 of 18 March 1987, issued by the Department, cited him for having exceeded the monthly time limits in December 1986.

1.6 Aircraft information

Aircraft
Make Boeing
Model727-21
Serial number 18999
Registration HK-1716
Date of manufacture 15 March 1966
Registration certificate No number. 26 November 1974
Certificate of airworthinessNo. 0103, valid 31 May 1988
Date of last ADCA inspection27 December 1987
Total time 43.848:02
Total time since overhaul9.824:31
Date and nature of last servicingPreflight inspection, 17 March 1988
Engines
Engines No. 1No. 2 No. 3
MakePratt and Whitney
Model JT8D-7A
Serial number 653469649611653371
Date and nature of last servicing March 17 1988. Preflight inspection
Total time 27 642:5233 566:4330.179:03
Total time since overhaul 9 500:00 2 157:022,556:03
History
HK-1716, owned by Avianca S.A.I came from Miami, Florida. U.S.A. and was registered with the Administrative Department of Civil Aviation on 30 October 1974.

Examination of the documentation for the aircraft established that the first overhaul was carried out in Barranquilla by airline technical personnel duly qualified for the equipment at 22,258 hours total time, and the last overhaul was carried out at 34,024 hours.

The technical log for 17 March 1988 contained only the following notes: "Please fix windshield wiper blades as per Maintenance Manual" and "Please clean cockpit windows". This was done before Flight 0410.

The regular periodic inspections were carried out normally, in accordance with the company programme. The last inspection by Civil Aviation personnel was carried out at Eldorado airport on 24 December 1987. and the aircraft was certified as airworthy and in compliance with the requirements of the Manual of Aeronautical Regulations (M.A.R).

The line check was carried out on 23 January 1988 by Flight Inspector Capt. on the scheduled Right over the Bogota-Bucaraman,aa-Bogota route. There were no comments relating to technical matters affecting flight safety.

The aircraft was refuelled with jet fuel at Camilo Data airport in C~icuta and began the Cbcuta- Cartagena flight with 21.100 pounds of fuel.

The weight and balance of the aircraft were calculated and found to he within the limits established for that particular aircraft type.

1.7 Meteorological information

The meteorological conditions at Camilo Data airport on the day of the accident, according to METARs. were as follows:

METAR 12:00 local time

Wind 360° at 18 km/h
Visibility 8 000 metres
Meteorological phenomena Smoke in E/SW quadrants
Clouds 3/8 cumulus at 2 300 ft; 5/8 cirrostratus at 20000 ft
Temperature 28°
Dew point 23°
QNH 1018
Relative humidity 74%

METAR 13:00 local time

Wind 360° at 28 km/h (15 kt)
Visibility 8 000 metres
Meteorological phenomena Smoke in all directions
Clouds 3/8 cumulus at 2 500 ft; 5/8 cirrostratus at 20 000 ft
Temperature 28°
Dew point 23
QNH 1017
Relative humidity 71%

METAR 14:00 local time

Wind 360° at 22 km/h
Visibility 8 000 metres
Meteorological phenomena Smoke in all directions
Cloud 3/8 stratocumulus at 2 500 ft; 6/8 cirrostratus at 20 000 ft
Temperature 30°C
Dew point 23°C
QNH 1016
Relative humidity 66%

According to statements by residents of the area, at the time of the accident the crash site, El Espartillo, was surrounded by heavy fog which reduced visibility to a minimum.

1.8 Aids to navigation

Camilo Data airport in the city of Clicuta is equipped with VOR and NDB, both of which were operating perfectly on the date and at the time of the occurrence.

HK-1716 was equipped with the following instruments: ADF (2), VOR (2), DME, ILS, flight director, weather radar and transponder. All were in perfect condition and operating normally.

1.9 Communications

Both Camilo Data airport and the aircraft were equipped with VHF and HF; voice recordings indicate that communications were normal at all times and took place on frequencies 118.1 and 119.9. 'ICAONote.-- The CVR transcript was not reproduced.

1.10 Aerodrome information

Camilo Data airport has 2 runways, with the following characteristics:
RUNWAY No.lNo.2
Orientation15/3302/20
107 000 kg 107 000 kg
Elevation 1 096 ft 1096 ft
2 320 m52.50 m
Length 2 320 m 1 920 m
Width 45 m 45 m
Class C C
Operating hours 10:00 to 02:00 UTC
Operating permit IndefiniteIndefinite
Owner FANFAN
Runway surfaceAsphalt pavementasphalt pavement
Average slope 0.0095% 0.006%
The facilities provided to users and operators meet the requirements established for this type c airport.
The Fire Fighting Service has T-6 vehicles, each with a capacity of 1.585 gal. of water and 205 gal. of AFFF foam, one rapid intervention vehicle with 750 Ib. of dry chemical powder and a total of 13 operators to handle any emergency.

1.11 Flight recorders

The aircraft flight data recorder was found approximately 20 days after the accident, and ita condition was consistent with the impact it had beensubjectedto. Itwas takento the NTSB laboratorise in Washington, where the velocity, altitude, head ing and G-force parameters recorded on the tape were found to be readable.

Below is a transcript of the results obtained, which are presented as a specific attachment in the appropriate section of the report.

TIME VELOCITYALTITUDEHEADINGGs
00:00:0 0 1 113 ft 200.1°*---
00:40:1 0 --- 262.4°*---
01:00:1 0 --- 248.7°* 1.06
01:30:2 0 --- 242.0°* 0.94
01:59:4 0 ___ 189.0°*1.10
02:20:9 0 ___ 148.2°* 1.08
03:00:1 0 ___207.1°* 1.05
03:36:3 0 ___ 333.2°+ 0.99
03:51:7 5 --- 333.0"= 1.07
03:59:9 10.0---335.7" 1.07
04:14:1 116.0 --- 334.0"0.90
04:31:0 156.0 --- 334.6"--
04:39:8 162.0 --- 338.3" 0.59
04:41:1 162.0 1 154 ft R 355.8" 0.88
05:00:8 172.0 1 637 ft329.3"0.79
05:32:5 191.0 2 169 ft 324.4" 0.90
06:01:4 218.0 2 478 ft314.0"1.08
06:34:9 250.0 3 210 ft305.1" 0.99
07:05:1 252.0 4 538 ft 287.0" 0.95
07:36:8 258.0 5 436 ft 296.0" 1.07
08:00:2261.06 040 ft314.0" 1.09
08:18:0280.06 343 ft M310.1"---
NOTE :
* Variable ramp and taxiing
+ Take-off position
= Beginning of take-off roll
R Rotation
M Moment of impact

1.12 Wreckage and impact information

According to the field inspection carried out at the accident site, the marks left by the imI: showed that the aircraft hit the flank of the mountain in normal flight attitude, nose up and sligl banked to the right. These facts were confirmed by the data read off the Aight recorders. Both figures and the graph of that reading indicated that at the time of impact the aircraft was travelling at : kt on a heading of 310.0" and at an altitude of 6 343 ft ASL, 657 ft short of clearing the peak.

The inspection also determined that the aircraft struck the rock at the angle between the ri wing root and the forward right fuselage. As a result, the left wing and fuselage were propelled in elliptical path by inertia, which threw the test of that part of the aircraft towards the upper part of peak to a distance of approximately 300 metres.

The central part of the fuselage and empennage were crushed at the point of impact and remains were partially covered by the avalanche produced by the impact. Some parts of the airer rolled down between the trees towards the ravine and stopped at different depths, the deepest be calculated at 750 m.

Identification of the wreckage located established that the engines had practically disintegra and only one retained its basic characteristics despite the damage. Parts of the main landing gear, ri flaps and aft stairs were also identified.

The level of destruction produced by the impact precluded complete identification of the other parts of the aircraft, as numerous fragments of the fuselage, wings and other components were scattered about indiscriminately Attached to this report is a polar diagram of the distribution of the remains over an area of 750 sq. m.

1.13 Medical and pathological information

The information obtained in this area indicates that the physiological state of the crew was normal before and during the flight. The voice recording made during the flight showed some animosity between the pilot and the flight engineer, while the co-pilot was in a calmer frame of mind. Attached to this report is the human factors study carried out subsequently on each member of the flight crew: it was established that they had all had a normal rest on the eve and day of the occurrence.

All crew members and passengers perished as a consequence of the crash and the state of their remains made it impossible: to carry out the appropriate autopsies; indirect evidence indicates, however, that no member of the crew had ingested any alcohol or drug that could have affected his capacity for the flight.

Documentation on removal of the remains and death certificates are attached to this report.

1.14 Fire

It was clearly established that there was no fire aboard the aircraft prior to the impact.

Because of the explosion and immediate scattering of remains, there was no generalized fire at the time of the accident either, although pieces of the fuselage showed the effects of small isolated blazes that were no doubt produced by friction between the metal plates and the rock but did not spread.

1.15 Survival

Not applicable. The report of the Aerocivil SAR unit on their post-crash activities is attached.

1.16 Tests and investigation

The site of the occurrence was duly examined to determine the position of the aircraft at the moment of impact, info -ion that was corroborated by the laboratory analysis of the voice and data recorders.

The NTSB readings of the latter are attached to this report and partially transcribed under the corresponding headings. The human factors investigation was conducted in consultation with the Aviation Medicine Division's Psychology Unit and interviews were held with family members and friends of the crew, as well as with Avianca personnel based in Bucaramanga. Important facts were established with regard to the personalities of the crew members, as well as their professional performance and habits. The psychologist's repon is attached.

With regard to Capt. habit of taking off and landing in VMC at Camilo Data airport, statistics for the current year were analyzed and showed that of 42 planned IFR landings, he cancelled 32 and proceeded VMC: with regard to departures, it was found that of 42 planned IFR departures, he cancelled 38 and proceeded on course VMC.

Of those flights, 7 were conducted via Airway W-19 to Cartagena or Santa Marta. Out of a total of 84 operations, he therefore cancelled 70, or 83.33%, of which 10% were VMC departures on course towards the coast.

1.17 Additional information

It should be noted under this heading that engine No. 3 of HK-1716 was changed on 2 February of this year because of a high EGT and stall. The JT8D-7, serial number 654518, was removed and replaced with a JT8D-7, serial number 653371.

In addition, the records of the Avianca Production and Control Department indicate that the aircraft was grounded on 12 February of this year due to problems with the rudder light and that the last servicing was carried out in Barranquilla on 28 February.

Documents provided by the Regional Manager of the Bucaramanga base indicate that on the day of the occurrence, the Bucaramanga - Cucuta - Cartagena - Barranquilla - Bucaramanga flight was running 2 hours 30 minutes late because HK-3133-X, the aircraft scheduled for the flight, was replaced in Bogota by HK-1716 for technical reasons (failure of the right windshield heat resistor in the cockpit).

It should also be noted under this heading that according to the testimony of the only eyewitness to the accident, the aircraft flew over the house of at an altitude equivalent to 75 feet above the ground (the height of a guama tree) and at that lime, 13:17 local time, there was dense fog over the peak. The aircraft disappeared into the fog and seconds later the witness heard the explosion of the impact with the mountain and saw what looked like "balls of fire rolling down the mountain."

1.18 New investigative techniques

Not used; proceedings were conducted in accordance with Circular DS-SA-09 dated 23 September 1985.

2.0 ANALYSIS

From the above information, it was clearly established that the delay in the schedule for 17 March, originally caused by a change of aircraft for technical reasons, put pressure on the pilot of HK- 1716 at the time of departure for Cartagena, so that when the controller in the Camilo Data Tower warned of a further 10-minute delay due to the presence of three aircraft on the VOR, Capt. decided to request a climb on course departure in order to avoid that delay. This, added to the anomalous presence in the cockpit of another pilot whose loquaciousness continually disrupted the work of all the crew members, affected the way in which the pilot supervised the actions of his co-pilot, who was flying the aeroplane. There was no crew briefing, nor did the pilot-in command give any instructions for the VMC departure. These factors, taken together, led the co-pilot, when he had taken off and barely reached the inner marker, to initiate a continuous turn to the lefi of the approach path. According to the FDR, the aircraft reached a heading of 286.4", and from that point oscillated between 286.4" and 310.1", at which heading it struck El Espanillo.

It was also noted from the conversations among the flight crew that they intended to achieve the highest possible speed first, then climb to the altitude needed to cross La Cuchilla, possibly through El Zulia canyon. This is inferred from the cockpit tapes of conversations, in which the pilot, when determining V1 and V2 referred to twenty-two ... thirty-eight, which is not consistent with calculations by aviation experts, according to whom V1 is 119 and V2 is 137.

Furthermore, the actual rotation speed of the aircraft (from the FDR) was 162 kt according to the NTSB; FDR data also show a constant increase in speed up to 280 kt, with a rate of climb lower than that required to clear La Cuchilla. These facts confirm the idea that the crew was more interested in speed than in altitude.

Another element to be considered is the fact that the presence of another aircraft on the approach path certainly created pressure and a resultant desire to keep turning to the left and avoid getting too close to the descending aeroplane. The deviation was so pronounced that three minutes after take-off, the non- crew pilot asked, "Do you think you're headed for Bogota? Stop fooling around," at which point the flight engineer, the only crew member who was attending to his job, said to the Captain, "Take a look at that fog ... Captain, (the flight engineer then laughed nervously) and the pilot-in-command told his co-pilot "in any case, start turning right." This shows the disorientation that prevailed in the cockpit at that moment.

In addition, the voice recorder established clearly that prior to the beginning of the flight the pilot-in-command did nut brief the co-pilot on the flight parameters (crew briefing, class of flight, heading, separation from the airway, etc.), and it can be deduced that the co-pilot was acting solely on the few phrases uttered by the pilot-in-command regarding the sequence of the flight.

2. 1 Fitness of the crew

From information obtained, we can confirm that the crew was physically and psychologically fit

for the flight in question. Their colleagues at Bucaramanga baseand their families described them as very professional. Nevertheless, it must be noted that while Capt. and Engineer had been with the airline for several years and could be considered by the latter to be good at their jobs, the co- pilot, Capt. , was almost new and lacked experience, having taken his course on the equipment only between February and April 1986. Considering the professional calibre of his captain, he was almost certainly concerned about doing a good job as co-pilot, and in the absence of proper supervision this affected his performance on the day of the accident. This conclusion is borne out by the comment from his instructor during his last simulator training session in August 1987: "Don't try to rush things.

In conclusion, the capacity and fitness of the crew, generally speaking, could be considered good but affected by the talkativeness of the non-crew pilot, whose chatter continually interfered with work in the cockpit.

2.1.1 Fitness of the air traffic controllers

Examination of the CVs of the two controllers manning the frequencies 118.1 (Control Tower) and 119.9 (Approach Control) on the date and at the time of the occurrence established that both were qualified to carry out their functions and their actions throughout were consistent with the relevant international standards.

The fact analyzed earlier, regarding ... [text missingl ... at that moment; the clearance requested by the pilot could be given without there being any danger associated with the aeroplane leaving the VOR because, by requesting to climb on course, the pilot assumed total responsibility for his separation from the other aircraft and control of the airspace used to reach the required flight level.

2.2 Airworthiness status of HK-1716

Information received regarding the aircraft indicated that the latter was airworthy on the day of the occurrence, ruling out the possibility of technical failure. This conclusion is borne out by the contents of the voice and flight data recorders, which give no indication of any anomaly related to mechanical failure of the aircraft.

3. CONCLUSIONS

Results
  • The crew in general met the technical and formal requirements for carrying out the flight in question;
  • There was no flight planning (briefing) to cover the pre-take-off period or the procedure for executing the requested climb on course;
  • The inappropriate presence of a non-crew pilot in the cockpit and his great talkativeness distracted part of the crew, which resulted in carelessness and disorientation in monitoring the heading and altitude necessary to cross La Cuchilla El Espartillo or to fly alongside it until reaching Radial 305 for airway Whisky 19.
  • The aircraft was airworthy, as attested by Certificate no. 0103 issued by the Administrative Department of Civil Aviation, valid until 31 May 1988;
  • The aircraft had been properly maintained in the Avianca shops by duly qualified technical personnel, in accordance with the standards established by the manufacturer and with the Aeronautical Regulations;
  • It was learned that the technical statistics concerning airframe and powerplant flight time were not recorded on a daily basis in accordance with the M.A.R., para. 4. 1.2.9;
  • The actions of the air traffic controllers were consistent with international standards and the aeronautical regulations. Their psychophysical and technical fitness to handle the flight in question was normal ;
  • Weather conditions in the airport vicinity were such as to permit authorization of VMC flight, but at the actual site of the occurrence there was thick fog in ail directions.
Causes

1. Active

A. Personnel factors - Pilot-in-command - Procedures, Regulations and instructions

a) Diverted attention from operation of aircraft and failed to exercise adequate and constant supervision over the performance of his co-pilot;
b) Tolerated inappropriate interference with cockpit discipline by authorized persons with access to the flight deck;
c) Continued VFR flight into IMC.

B. Personnel factor - Non-crew pilot in cockpit - Procedures, regulations and instructions

Interfered constantly with the normal operation of the aircraft, distracting the crew from the efficient execution of their duties.

2. Passive

A. Personnel factor- Crew- Procedures, regulations and instructions: lack of teamwork on the part of the crew, reflected in the failure to coordinate the instructions needed to take off and climb out in VMC using a profile established in accordance with the specific conditions.

B. Other factors - Meeting the schedule: The delays resulting from the change of aircraft for mechanical reasons contributed to the decision by the pilot-in-command to give inappropriate support to company priorities and request to depart, rather than waiting as recommended by the Control Tower, in order to avoid adding to the delays already experienced.

4.0 RECOMMENDATIONS

1. That airlines supervise the manner in which their crews comply with the standards established in the M.A.R., Part IV, Chapter I, Para. 4.1.1.2, which says: "Authority and responsibility of the pilot- in-command, The pilot-in-command is responsible for the operation and safety of the aircraft. Both crew members and passengers are subject to his authority.

2. Remind airlines and pilots that in accordance with Administrative Order no. 1219 of 5 February 1986, the use and application of the Manual of ATS Standards, Routes and Procedures, developed by the Administrative Department ofCivil Aviation, is mandatory for all airlines, for pilots flying in Colombian airspace and for air traffic controllers within the country.

3. That airlines comply with the regulations in the M.A.R., Part IV, para. 4.1.2.9, concerning daily recording of the flight time of airframes, powerplants and other components that require such records.


Copyright © 1996-1999 Harro Ranter / Fabian Lujan
Aviation Safety Network; updated 12 August, 1999