Independent Air Flight 1851 Aftermath Footage | 8 February 1989 Santa Maria, Azores, Portugal

Описание: Accident Description:
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𝗜𝗻𝗱𝗲𝗽𝗲𝗻𝗱𝗲𝗻𝘁 𝗔𝗶𝗿 𝗙𝗹𝗶𝗴𝗵𝘁 𝟭𝟴𝟱𝟭 was an international charter flight from Bergamo to Punta Cana with an intermediate stop in Santa Maria. The flight was being operated by a Boeing 707 (Reg. N7231T) on 𝗙𝗲𝗯𝗿𝘂𝗮𝗿𝘆 𝟴, 𝟭𝟵𝟴𝟵.

The plane departed Bergamo at 10:04 UTC. At 13:56:47 Santa Maria Tower cleared the flight to descend to 3,000 feet for a runway 19 ILS approach. In that transmission, the trainee controller had transmitted an incorrect QNH that was 9 hPa too high. In the cockpit, the first officer questioned aloud the QNH value, but the captain agreed that the first officer had correctly understood the controller. After being cleared for the ILS approach the crew failed to accomplish an approach briefing, which would have included a review of the approach plate and minimum safe altitude.

If the approach plate had been properly studied, they would have noticed that the minimum safe altitude was 3,000 feet and not 2,000 feet, as it had been understood, and they would have noticed the existence and elevation of Pico Alto. At 14:07:52, the captain said, "Can’t keep this SOB thing straight up and down". At approximately 14:08, the radio altimeter began to whine, followed by the GPWS alarm as the plane began to climb because of turbulence, but there was no reaction on the part of the flight crew. At 14:08:12, the plane was level when it impacted a a mountain ridge of Pico Alto. It collided with a rock wall on the side of a road at the mountain top at an altitude of approximately 1,795 feet AMSL.

𝗣𝗿𝗼𝗯𝗮𝗯𝗹𝗲 𝗖𝗮𝘂𝘀𝗲:
"The Board of Inquiry understands that the accident was due to the non-observance by the crew of established operating procedures, which led to the deliberate descent of the aircraft to 2000ft in violation the minimum sector altitude of 3000ft, published in the appropriate aeronautical charts and cleared by the Santa Maria Aerodrome Control Tower.
Other factors:
1) Transmission by the Santa Maria Aerodrome Control Tower of a QNH value 9 hPa higher than the actual value, which put the aircraft at an actual altitude 240ft below that indicated on board.;
2) Deficient communications technique on the part of the co-pilot, who started reading back the Tower's clearance to descend to 3000ft before the Tower completed its transmission, causing a communications overlap.;
3) Violation by the Aerodrome Control Tower of established procedures by not requiring a complete read back of the descent clearance.;
4) Non-adherence by the crew to the operating procedures published in the appropriate company manuals, namely with respect to cockpit discipline, approach briefing , repeating aloud descent clearances, and informal conversations in the cockpit below 10000ft.;
5) General crew apathy in dealing with the mistakes they made relating tot the minimum sector altitude, which was known by at least one of the crew members, and to the ground proximity alarms.;
6) Non-adherence to standard phraseology both by the crew and by Air Traffic Control in some of the air-ground communications.;
7) Limited experience of the crew, especially the co-pilot, in international flights.;
8) Deficient crew training, namely concerning the GPWS as it did not include emergency manoeuvres to avoid collision into terrain.;
9) Use of a route which was not authorized in the AIP Portugal.;
10) The operational flight plan, whose final destination was not the SMA beacon, was not developed in accordance with the AIP Portugal."