Kano

The following findings were identified:
- The flight departed Ostend before overflight clearances and landing permits had been obtained for the route. The captain believed that authorizations had been received by the London office, after speaking to the London representative.
- There is no effective dispatch of flight watch system established by the carrier for overseas cargo operations.
- The flight proceeded directly from Tamanrasset to Kano rather than following its planned routing to N'Djamena.
- In order to justify landing at Kano the crew had to declare a false fuel emergency.
- The crew had insufficient time in Kano to fully plan the leg to Kisangani, taking into account all of the factors affecting the safety of the flight.
- The aircraft did not carry enough fuel to comply with the minimum alternate requirements.
- The selected alternate (Bunia) was not suitable.
- The selected route depended on enroute radio aids which were published as being unlikely to be available. This information was available to the crew during the planning and conduct of the flight.
- There was no evidence available to the crew that the KGI VOR and the KW NDB, the navigation and approach aids at Kisangani, would be off the air.
- The aircraft’s flight plan was not passed to Kisangani, and so the flight was not expected on the morning of the accident.
- Prior permission to use Kisangani was not requested nor received on the night of the accident.
- The crew did not use radar for navigation during the last leg of the flight.
- The weather conditions which existed at Kisangani upon arrival would have permitted a landing using the Jeppesen published approach procedure.
- The crew was misled by a bearing indication from the LU NDB at Luanda, whose frequency almost coincided with that of the KW NDB at Kisangani. This led them to descend to low altitude and to continue predominately southwest for the remainder of the flight.
- The weather during the last hour of flight would have been suitable for celestial navigation. The aircraft did not carry a navigator, VLF or INS navigation systems.
- The carrier’s marketing and sales literature overstates the payload capability of the aircraft.
- Due to a lack of operational expertise, the carrier’s marketing and sales managers are overselling the aircraft for the stage lengths involved.
- Hercules Captains are knowingly exceeding MTOW limitations.
- Hercules Captains are knowingly flying with insufficient fuel for standoff and alternate requirements.
- There is direct and indirect pressure on the crews to exceed aircraft limitations and to take off without sufficient fuel to meet normal standoff and alternate requirements.
- The airplane departed Kano approximately 6,600 lbs over the MTOW.
- Company representatives scheduled cargo flight crews to exceed flight duty time limitations on charter operations out of Stansted.
- The Captain knowingly exceeded duty time limitations on the accident flight and on a number of prior occasions.
- The crew duty time on the accident flight was at least 34 hours and probably 42 hours.
- There was evidence of crew fatigue 14 hours before the accident.
- Crew fatigue was evident 2 hours before the accident.
- The flight plan and ETA of the aircraft were not forwarded to the Kisangani ATS unit due to lack of adequate communication between Kinshasa and Kisangani tower.
- Navigation Aids (GEM NDB, LIS NDB) along the last 439 NM of planned route from Libenge to Kisangani were published in Republic of Zaire AIP as not being available during the time of flight.
- The VOR and NDB’s at Kisangani are normally in operation on a 24 hours basis.
- Use of the Kisangani aerodrome is restricted to VFR only.
- Use of the Bunia aerodrome (filed alternate) is restricted to VFR only.
- Communications with radio operators at significant points along the route of flight in Zaire are published as not available during night.
- The aircraft was unable to maintain radio contact either directly or indirectly with the Kinshasa FIC due to inadequate HF signal reception.
- The aircraft did not communicate with any aeronautical ground station in Zaire.
- No air traffic services (Control Service, Flight Information Service or Alerting Servic) were provided for the aircraft by Zaire ATS authorities during the aircraft’s flight due to inadequate communications facilities.
- Alerting Service for the aircraft was begun by Kinshasa FIC at 0440Z on 21 November, 2 hours 52 minutes after entering the uncertainty phase – 20 minutes after the aircraft had crashed.
- Alerting service for the flight did not conform to International Standards and Recommended Practices as detailed in ICAO Annex 11, Chapter 5.
- The aircraft was within reception range of VHF, VOR and NDB facilities at Kisangani for 53 minutes between 0224Z and 0317Z on the morning of the accident.
- The crew of the aircraft attempted unsuccessfully to contact Kisangani Tower on 118.1 MHz while within reception range. One other aircraft failed to make contact during the same period. Both aircraft had functional VHF transceivers at the time.
- C-FPWX and the other aircraft attempted unsuccessfully to receive navigational signals from the KGI VOR, KE NDB and KGI NDB while within reception range. C-FPWX had functional ADF receivers during this time. The other aircraft had functional VOR receivers.
- The VHF receiver (118.1 MHz) and the HF/CW receiver at Kisangani were either unserviceable or unmanned during the 6 hour and 40 minute period between 2255Z on November 20 and 0535Z on November 21.
- None of the navigational radio aids at Kisangani was functioning on the morning of the accident.
- The crew did not make full use of available HF/SSB facilities in an emergency situation.
- The crew delayed their declaration of an emergency unnecessarily. The aircraft was beyond VHF reception range of Kisangani during all VHF emergency calls. They did not manually activate their ELT or select the emergency transponder code.

The accident was the consequence of a fuel exhaustion caused by probable navigational errors on part of the crew who lost his orientation in poor weather conditions.

The exact cause of the accident remain unclear. Nevertheless, it is believed that control was lost on short final due to wake turbulences and the aircraft adopted a nose-down attitude before crashing onto the runway.

The exact cause of the accident could not be determined with certainty. The FDR was found undamaged but the British AAIB engineers reported it was unreadable as the data consisted only of a stream of alternating ones and zeros. Apparently there had been a fault in one of the logic units of the system, something which could not be detected from the flight deck. No readable data could be reconstructed from this. Nevertheless, it is believed that the flying crew led the aircraft descending below the minimum safe altitude while still under control.

The accident was the result of an error of judgement on the part of the captain, who, after sighting the runway lights, concentrated on keeping them in sight and failed to make adequate reference to his flight instruments. As a result, he allowed the aircraft to descend below the obstacle clearance limit of 360 feet. In the darkness with no ground reference, the distant runway lights gave him insufficient guidance as to his height and angle of approach, and he was unaware that the aircraft had descended to ground level. The fatigue of the captain and the failure to put the aircraft's landing lights ON were considered as contributing factors.

The accident was the result of loss of height and airspeed caused by the aircraft en- countering, at approximately 250 feet after takeoff, an unpredictable thunderstorm cell which gave rise to a sudden reversal of wind direction, heavy rain, and possible downdraught conditions.

Causes of the accident, in chronological order, are set out by the report as follows:
- Faulty use by the navigator of the variation setting control on the CL2 Gyrosyn compass,
- Faulty checking of compasses by incorrect astral bearing and without the aid of radio bearings,
- Incorrect inference drawn by the captain in pronouncing the CL2 Gyrosyn compass correct and the P.12 magnetic compass unserviceable,
- Fault on the part of the captain in not returning to Tripoli when the P.12 compass was regarded as unserviceable (in breach of BOAC regulations),
- Inability of the crew to realize that astro shots were being taken on the wrong stars,
- Inability of the crew to determine the aircraft's position properly by the standard methods when the VSC setting error was discovered,
- Lack of decisive action on the part of the captain once he knew he had lost his way,
- Ignorance, on the part of those on board, of the assistance which could have been afforded by Atar airfield.