Disaster after ignoring 28 seconds

February 21st 2008, Santa Barbara Airlines flight 518 is preparing for a flight to Carcass from Alberto Carnevalli Airport Merida, Venezuela. Aldino Garatina Gomez is today’s Captain (age 36). He is a flight instructor and a senior pilot in the airline with 5000 hours of experience. The First Officer is Denis Ferreira Quintal (age 28). There are 46 people on board including a crew of three people. The plane today is a 21year old ATR-42-300. Alberto Carnevalli Airport has only one runway and the pilots are informed about a pending approach.

Photo: wikiwand.com

Controllers tell the pilots to conduct their departure or wait for the incoming flight to land. The pilots chose to depart immediately as they align at runway 25. The First Officer is the pilot flying the plane and moments later they set their thrust levers and the plane starts rolling for take off. Minutes later after take off the GPWS (Ground proximity warning system) sounds off and the Captain takes control of the plane and the pilots start discussing about their heading. Moments later confusion rises up about the heading and about commencing a right turn while the GPWS continues to give warnings.

Photo: aircrashconsultants.com

The F/O suggests a turn around after he notices they are losing altitude. The pilots make visual contact with the terrain ahead and realise they are heading towards the mountains ahead. The captain starts to pull the yoke in an attempt to raise the nose but the F/O is still concerned whether they will make it and he starts calling out the Captains name in fear. The captain tries to keep calm by telling him to hold on but moments later, Santa Barbara Airlines flight 518 crashes into the Andes mountains 10km from Merida. The plane impacted a rock named as “Indian face” at 13 400 ft. Sadly…everyone on board is killed.

Photo: airflightdisaster.com

Investigators quickly started their work and discovered the plane did not crash anywhere near its initial planned flight route. The official arrival and departure route of the airport is the Rio Charma corridor to the west of their airport. Planes flying away have to make a 180 degree fight turn to the west of the airport around the valley. The crew of flight 518 used an un-published approach and departure route called “Observatorio” as it passes over an astronomical observatory. Apart from being unpublished, the route saves flights 15 minutes on the route to Caracas but it was noted the plane did not crash on the “observatorio” route either. Investigators learned that the crew did not make a 180 turn to the left as the ‘observatorio’ route normally. The plane did not stop until making a 270 degree turn towards the mountain.

Photo: timenote.info

Both pilots could not agree on the direction they were headed to. Further review of the CVR indicated the the pilots were in a rush to prepare the plane for take off. This including request for startup clearance when in the middle of startup. They also failed to conduct their pre-flight checklist. As the plane was taxiing the Captain stated that the planes gyroscopes were not working. (The gyroscopes state the planes pitch and roll). The planes AHRS ( altitude and heading reference) provides the pilots with information about their pitch yaw and roll. A check on the ATR systems stated that the plane’s navigation system takes three minutes to start up meaning that the plane had to be still for three minutes so that the gyroscopes, accelerenometers and magnetometers sync up however the pilots started taxiing two minutes later after start up. The hurried take off left the navigation systems offline as they believed they could reset their instruments during flight.

Pboto: airflightdisaster.com

It was practically impossible to maintain a flight straight enough and level enough for the gyroscopes to synchronize in the air. The CVR revealed that the pilots used the standby magnetic compass as they waited for their systems to go online. Investigators retraced the flights steps to get a reason for the rush. They easily learned the pilots left the plane in between flights to relax at the airport terminal cafe. They began conversations and lost track of time. They arrived at the plane 30 minutes late after the last passenger had boarded 7 minutes prior to take off. Had they waited 28 seconds before moving, the systems could have worked properly.

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Published by mbire9

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