Zone

Crash of a Cessna 500 Citation I in Santiago de Compostela: 2 killed

Date & Time: Aug 2, 2012 at 0618 LT
Type of aircraft:
Operator:
Registration:
EC-IBA
Flight Type:
Survivors:
No
Schedule:
Oviedo - Santiago de Compostella
MSN:
500-0178
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3600
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
678
Copilot / Total hours on type:
412
Aircraft flight hours:
9460
Circumstances:
Based on the information available, at 20:40 the ONT (National Transplant Organization) informed the Santiago Airport (LEST) that they were going to make a “hospital flight”. The aircraft was refueled at the Santiago Airport with 1062 liters of fuel. According to communications, the crew of aircraft EC-IBA contacted the Santiago tower at 21:46 to request permission to start up and information on the weather and the runway in use at Asturias. At 21:54 they were cleared to take off. According to the airport operations office, the aircraft landed in Asturias (LEAS) at 22:27. The hospital flight service commenced at 22:15. The RFFS accompanied the ambulance to the aircraft at 22:30 and at 22:44 the aircraft took off en route to Porto. The aircraft was transferred from Madrid control to Santiago approach at 22:52 at flight level 200 and cleared straight to Porto (LPPR). Based on the information provided by Porto Airport, the aircraft landed at 23:40. While waiting for the medical team to return, the crew remained in the airport’s facilities. According to some of the personnel there, the crew made some comments regarding the bad weather. There was fog, especially on the arrival route. At 01:34 and again at 02:01 the crew was supplied with the flight plan information, information from the ARO-LPPR office and updated weather data. The aircraft was refueled at the Porto Airport with 1,000 l of fuel and took off at 02:34. At 02:44 the aircraft contacted approach control at Santiago to report its position. Four minutes later the crew contacted the Santiago tower directly to ask about the weather conditions at the field (see Appendix C). The aircraft landed once more in Asturias at 03:28. At 03:26 the RFFS was again activated to escort the ambulance to the aircraft. The service was deactivated at 04:00. The crew requested updated weather information from the tower, which provided the information from the 03:00 METAR. According to the flight plan filed, the estimated off-block time (EOBT) for departing from the Asturias Airport was 03:45, with an estimated flight time to Santiago of 40 minutes. The alternate destination airport was Vitoria (LEVT). The aircraft took off from Asturias at 03:38. At 03:56 the crew established contact with Santiago approach control, which provided the crew with the latest METAR from 03:30, which informed that the runway in use was 17, winds were calm, visibility was 4,000 m with mist, few clouds at 600 ft, temperature and dew point of 13° and QNH of 1,019. The aircraft was then cleared to conduct an ILS approach to runway 17 at the Santiago Airport. At 04:15 the crew contacted the tower controller, who reported calm winds and cleared them to land on runway 17. At 04:18 the COSPAS-SARSAT system detected the activation of an ELT. The system estimated the position for the beacon as being in the vicinity of the LEST airport. At 04:38 the tower controller informed airport operations of a call he had received from SAR that a beacon was active in the vicinity of the airport, and requested that a marshaller go to the airport where the airplane normally parked to see if it was there. At 04:44 the marshaller confirmed that the aircraft was not in its hangar and the emergency procedure was activated, with the various parties involved in the search for the airplane being notified. At 05:10 the control tower called the airport to initiate the preliminary phase (Phase I) before activating the LVP. At 05:15 the RFFS reported that the aircraft had been found in the vicinity of the VOR. At 05:30 the LVP was initiated (Phase II). At 07:51 the LVP was terminated. The last flight to arrive at the Santiago Airport before the accident had landed at 23:33, and the next flight to arrive following the accident landed at 05:25.
Probable cause:
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.
Final Report:

Crash of a Beechcraft 350C Super King Air in Santiago de Compostela

Date & Time: Jun 7, 2001 at 0213 LT
Registration:
F-GOAE
Flight Type:
Survivors:
Yes
Schedule:
Le Mans - Santiago de Compostela
MSN:
FM-1
YOM:
1990
Flight number:
OPE062
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3115
Captain / Total hours on type:
211.00
Copilot / Total flying hours:
791
Copilot / Total hours on type:
268
Aircraft flight hours:
5331
Aircraft flight cycles:
7451
Circumstances:
While on approach to Santiago de Compostela Airport, around 0000LT, meteorological conditions were reported to be good, and the crew requested a visual approach to runway 17, even though the active runway was 35. Once cleared to land, the aircraft encountered a fog patch and from this moment it began a high rate descent (2,000 to 3,000 feet per minute). A minute after entering an unexpected and unforeseen fog patch, at 00:13:02 of June 7, the aircraft struck some trees, in level flight and with an airspeed of 148 knots. The wings and engines detached from the fuselage, and they dragged along a scrubland area until they came to a stop. The crew suffered minor injuries and the aircraft was completely destroyed.
Probable cause:
The probable cause was the decision to start a visual approach without having the runway in sight and the continuance of the visual approach in spite of the loss of external visual references, as they unexpectedly entered a fog patch.
Final Report:

Crash of a Canadair CL-215-1A10 in Santiago de Compostela: 4 killed

Date & Time: Sep 9, 1988 at 1500 LT
Type of aircraft:
Operator:
Registration:
UD.13-4
Flight Phase:
Flight Type:
Survivors:
No
MSN:
1032
YOM:
1973
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After takeoff, while climbing, the right engine failed. The aircraft lost height and crashed, killing all four crew members. They were on their way to perform a scooping mission before flying to the region of Orense to fight a forest fire.
Probable cause:
Failure of the right engine during initial climb for unknown reasons.

Crash of a Douglas DC-8-63 in Santiago de Compostela

Date & Time: Mar 3, 1978 at 1725 LT
Type of aircraft:
Operator:
Registration:
EC-BMX
Survivors:
Yes
Schedule:
Madrid - Santiago de Compostela
MSN:
45930/378
YOM:
1968
Flight number:
IB575
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
211
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Circumstances:
After touchdown on a wet runway at Santiago de Compostela Airport, the crew activated the thrust reverser systems and started the braking procedure. Unable to stop within the remaining distance, the airplane overran, lost its undercarriage and came to rest in flames in a wooded area, broken in two. All 223 occupants were evacuated, 52 of them were injured, some seriously. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the flying crew who continued the approach above the glide and landed too far down the runway, reducing the braking distance available. The braking action was also limited because the runway surface was wet, which was considered as a contributing factor.

Crash of a Canadair CL-215-1A10 near Pontevedra: 3 killed

Date & Time: Sep 8, 1976 at 1800 LT
Type of aircraft:
Operator:
Registration:
UD.13-7
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Santiago de Compostela - Santiago de Compostela
MSN:
1035
YOM:
1974
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew departed Santiago de Compostela on a fire fighting mission in the region of Pontevedra. In unknown circumstances, the airplane crashed on the slope of Mt Xiabre and was destroyed. All three crew members were killed.

Crash of a Bristol 170 Freighter 21 in Madrid: 37 killed

Date & Time: May 9, 1957 at 1904 LT
Type of aircraft:
Operator:
Registration:
EC-ADI
Survivors:
No
Schedule:
Santiago de Compostela – Madrid
MSN:
12757
YOM:
1946
Flight number:
AO111
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
37
Captain / Total flying hours:
5478
Copilot / Total flying hours:
427
Circumstances:
The aircraft was on a scheduled passenger transport flight from Santiago de Compostela to Madrid, carrying 32 passengers and 5 crew. As requested, the flight passed downwind to align itself for landing on the assigned runway 23 during which maneuver the control tower gave it the green light for landing. The aircraft went by at an altitude of about 300 metres, banking slightly to the left in order to see the light signal more easily. At 1904 hours it saw the green light, compensated for its left bank and, banking to the right, started a right spin which continued to the ground. The aircraft hit the ground with the front part of the fuselage, the right wing and the right engine propeller and caught fire. Although the airport fire fighting services reached the aircraft 6 minutes after the accident and promptly went into action, it was impossible to extinguish fire completely for more an hour. Its effects, however, were reduced to such an extent that the crew and passengers could have been saved had they not all died as a consequence of the violent impact.
Probable cause:
The accident was due to personnel errors.
1) The failure of radiotelephony compelled the pilot to concentrate on the green light during the approach manoeuvre,
2) The pilot's attention was so distracted that he operated close to the speed limit. Although such a distraction is infrequent, statistics show that it may occur after 5 000, 7 000 and even after 13 000 flying hours.
Final Report:

Crash of a Casa 352 in Monterroso: 4 killed

Date & Time: May 9, 1951
Type of aircraft:
Operator:
Registration:
T.2-93
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Santiago de Compostela – León
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
About twenty minutes after his departure from Santiago de Compostela, the crew encountered poor weather conditions with thunderstorm activity. The aircraft went out of control and crashed on a mountain located near Monterroso. All four crew members were killed.