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Accident Prevention
Vol. 52 No. 2 For Everyone Concerned with the Safety of Flight February 1995
On Feb. 8, 1989, Independent Air 1851 (IDN 1851), a Boeing The report said, “The [U.S. Federal Aviation Administration
707-331B, while in clouds and heavy turbulence and after (FAA)] principal operations inspector (POI), [who was]
seven seconds of “whoop whoop, pull up” from its ground- responsible for Independent Air, was assigned in 1987 and
proximity warning system (GPWS), flew into Pico Alto, a was also responsible for two other operators. He was not
mountain on the island of Santa Maria, Azores, Portugal. The qualified in the B-707. He spends about 25 [percent] of his
aircraft was destroyed and there were no survivors among the time working Independent Air, by maintaining daily telephone
137 passengers and seven crew members. contact, visits to corporation (headquarters) about three times
a month and does flight inspections twice a year.
U.S. Oversight Weak in
International Operations “He supervised instruction classes several times, not following
them to completion. He also observes simulator training, but
Independent Air was a small charter company based in Smyrna, is not qualified to give check rides [which were performed by
Tennessee, U.S., that operated two Boeing 707s, according to other FAA personnel from Dallas, Texas, and Miami, Florida,
the official accident report prepared by the Portuguese General where B-707 simulators were located].
Directorate of Civil Aviation, Department of Accident
Prevention and Investigation. The company’s traffic was “From Jan. 1, 1988, to Feb. 8, 1989, the date of the accident,
generated primarily by tour operators, but the company also there were 118 inspections, covering flight operations,
contracted unscheduled flights for the U.S. military. airworthiness of the aircraft, training and check rides of the
flight crews, maintenance, aircraft records, weight and balance,
The accident aircraft was manufactured in 1968 for Trans etc.,” the report said. The report noted that the number of
World Airlines, and was currently owned by IAL Air Services inspections was typical for this kind of operation but “that it
Inc., which leased the aircraft to Independent Air. At the time was not possible to determine [their] efficiency.”
of the accident, the aircraft had logged 44,755.3 hours and
12,589 landings, with 186.9 hours and 48 landings since its The report said that there were 12 checks on international
last inspection. operations from Dec. 14, 1986, through Jan. 15, 1989. Three
of those checks were on Atlantic Ocean routes, but Santa Maria GPWS Training Excluded
was not among them.
From Simulator Checks
The report said, “Although 12 line inspections on international And Instruction Manuals
routes were given, it is the belief that the inspectors did not
have adequate experience and knowledge,” the report said. It The report said that after the NTSB recommendations were
also noted the limited experience of the crew in international made, the FAA issued on Aug. 12, 1987, changes to the Air
operations and in the airspace in which the crew was operating Carrier Operations Bulletin (ACOB) that required “a review
at the time of the accident. of flight manuals and training programs to assure compliance
with [Federal Aviation Regulations (FARs) Part 121.360],
The report added: “However, it was verified that the principal which required that these manuals contain adequate
operation[s] inspectors were not given special training, which information regarding the actions to take by the flight crews
would allow them to adequately check international operations upon hearing the GPWS alarm, and that the flight training
except for over-water navigation. programs, initial and recurring, have the appropriate
information for the instructors and
“It is a fact that, although there is almost examiners with respect to the response[s]
universal adherence to ICAO [International of pilots facing the GPWS.
Civil Aviation Organization] standards “… because the
regarding air traffic control phraseology and “However, it is verified that the inspectors
procedures, there are several countries that simulator’s GPWS in charge of Independent Air ignored this
use peculiar phrases and procedures. change to the ACOB, and there was no
would activate during mention in the instruction manual of
“Navaids [navigation aids] are fewer and normal approaches, Independent Air of information on the
sometimes less reliable. The English used response to the GPWS.”
by [air traffic control], although fluent, can instructors usually
present an accent that is difficult to Independent Air’s flight training was
understand for [U.S.] pilots, especially if
disabled the system or conducted in simulators that were owned
the international experience is limited. instructed the students by other airlines — one in Texas and one in
Florida. During the accident investigation,
“Sometimes some sounds are not not to react when the it was learned that “the simulators were not
pronounced the same as in English, such as programmed for the same approach speeds
‘th’ in the word ‘three.’
GPWS would sound.” and flap settings as used by the accident
aircraft, because [the simulators] had not
“On the other hand, the national language been modified with the installation of ‘hush
is used by domestic operators and is not understandable to kits.’” [Hush kits were installed on the B-707s operated by
North American flight crews, who can be taken by surprise by Independent Air.]
maneuvers of others [who have been communicating in their
native languages, not English]. “Thus, because the simulator’s GPWS would activate during
normal approaches, instructors usually disabled the [GPWS]
“Recognizing this situation, the NTSB [U.S. National or instructed the students not to react when the GPWS would
Transportation Safety Board] recently issued, on a date prior sound,” the report said.
to the accident, two recommendations with the purpose of
having the FAA instructing their inspectors to pay more Independent Air’s operations manual did require that “if a
attention to air carriers involved in international operations ground-proximity warning is observed or heard immediately
[necessary] to increase flight crew vigilance when operating execute a pull-up and apply go-around thrust. Maintain
in airports outside the United States, and to verify if flight maximum rate of climb consistent with speed and configuration
crew instruction programs [are] adequate for safe international until warning ceases.”
operations.
He received his private pilot certificate in 1980. He was During the investigation, “the flight engineer was described
employed as a flight instructor, first officer, captain and chief by his colleagues as being an outstanding professional … .”
pilot by several Tennessee companies from 1983 until October He reportedly maintained a personal set of navigation charts
The accident report considered how the “psychic and physical” Aeronautical Information Suffered from
conditions of the crew members might have “interfered with 27 Years of Handwritten Changes
the necessary ‘availableness’ of the psychic performance of
their duties” and noted that these medical conditions were not The report said that during the investigation, it was discovered
on file with the FAA. that “words from the ICAO phonetic alphabet were used to
designate significant points of lateral limits of the Regional
Terminal Control Area of Santa Maria, which contributed to
Delays Resulted in Crew’s the fact that the Oceanic Clearance was not clearly understood
Assignment to Accident Aircraft by the flight crew and that there were difficulties on the
comprehension of the Selcal of the aircraft by the air traffic
After traveling to Montego Bay, Jamaica, on Feb. 3, 1989, the controller on duty.” [Selcal (selective calling) enables ATC to
three crew members flew on Feburary 4 from Montego Bay to make radio calls to specific aircraft by electronically using
Fort Worth, Texas, and then to Denver, Colorado. The route four-letter designations.]
was reversed on the return trip and the crew arrived in Montego
Bay on February 5. The three crew members were reassigned The report added, “aeronautical information for this region,
the same day to IDN 1851 because of crew duty-time problems included in the AIP-Portugal, was not properly updated [since
caused by delays on their previous flight. 1962], containing a number of errors, omissions and
impreciseness (sic), not in conformity with international rules
The crew arrived in Genoa, Italy, on Feb. 7, 1989, after a 10- adopted by the Portuguese Republic.
hour and 40-minute overnight flight from Montego Bay. They
were scheduled originally to land at Malpensa, near Milan, “Regarding the [Santa Maria Aeronautical Charts and the
but the flight was diverted because of fog. They traveled by Instrument Approach and Landing Charts, which were dated
bus for three hours to Bergamo, northeast of Milan, for a 46- Feb. 1, 1962], for the last 27 years handwritten corrections were
hour layover near their scheduled departure airport. Their used without the proper registration and quality, which had not
activities in Bergamo are unknown, but they appeared occurred with the remaining aeronautical charts of other airports,
cheerful when departing the hotel early in the morning of which had their charts reviewed between 1984 and 1988, with
February 9, said the report. the exception of one chart of 1973. The accumulation of
[handwritten] amendments and notes and the significant change
Their return flight was rescheduled to depart from Genoa, of the procedures on instrument approaches required by itself
because of forecasted fog. Nevertheless, after the fog cleared the revision of these charts, which did not occur, in violation of
unexpectedly, the inbound flight was able to land at Bergamo the rules that determine the revision of aeronautical charts.”
at 0720 UTC [all times are Coordinated Universal Time]. The
aircraft, scheduled for departure at 0800, departed at 1004 for The report said that restrictions against using the Santa Maria
its four-hour and 10-minute flight to Santa Maria. very high frequency omnidirectional radio range (VOR) as a
primary navigation aid were not published in the AIP-Portugal,
The report said, “The operational flight plan supplied by and invited the VOR’s use as a primary navigation aid in the
Lockheed Data Plan, designated the arrival point as LPAZ with terminal area. Moreover, citing ICAO’s requirements, the
ground coordinates of N36756 [latitude] and W025096 report said the “ primary navigational aid in a terminal region
[longitude] that . . . does not correspond to ground coordinates must be a VOR, that must be installed in a location that permits
of any of the navaids of Santa Maria [Airport] or the airport the most efficient possible approach procedures. The NDBs
reference point. Therefore this flight plan was not made must be used for holds when it is not possible or practical to
according to the established procedures in the [Aeronautical install a VOR for that purpose.”
Information Publication (AIP)-Portugal], which indicates as
an entering route ECHO [a compulsory reporting point]-NDB The report said, “Therefore, because it is usual in the United
[nondirectional beacon]-SMA [Santa Maria].” States and Europe to use a VOR to define ATS [Air Traffic
The antenna was not marked on the aeronautical charts and SMARTF IDN 1851 1248:24 Negative Selcal will you
no license had been issued to permit its erection, although its try again Echo Mike Alfa Lima
existence resulted in minimum altitudes being too low and
1248:28 Selcal
“jeopardized the safety of flights in this area.”
SMARTF IDN 1851 1248:34 Roger Selcal checked
Many other specific anomalies of the Santa Maria information this time
were cited, but the report said “these did not contribute in any
way to the accident.” IDN 1851 SMARTF 1255:00 Independent one eight
five one Santa Maria
Data Showed Difficulties with Routine SMARTF IDN 1851 1256:47 Santa Maria Radio Santa
Radio Communication Maria Independent one eight five one position
During the flight, the crew of IDN 1851 and air traffic SMARTF IDN 1851 1258:50 Santa Maria Radio
controllers experienced reception difficulties on the high Independent one eight five one position
frequency (HF) channels [see transcript of excerpted
IDN 1851 SMARTF 1258:55 Independent one eight
communications, at right] used for communication during the
five one stand by
flight; there were no indications of equipment problems on
the aircraft or on the ground.
The report said that the first officer gave incomplete readbacks The report continued: “On HF and VHF [very high frequency]
of the clearance [at 1247:05 and at 1247:38] regarding the communications, it can be noted that [17] groups of numbers
route, ECHO Sierra Mike Alpha, “which ended up being were transmitted with a maximum of four numbers of which
accepted by the aeronautical station [controller], who only eight of them had to be repeated due to lack of comprehension
required the correction of the Mach number and the Selcal of by the copilot revealing bad communications technique as well
the aircraft ... .” as the non use of standardized phraseology.”
The report said “the identification of the final approach fix At 1343:57 [see cockpit voice recorder (CVR) transcript, page
was never clearly understood by the flight crew. The two 8], the flight engineer contacted Santa Maria Approach and
readbacks omit the name of the final approach fix. The first requested the current meteorological report. The report said
[readback] ends on ECHO and the second [readback] refers that this was the only communication made by the flight
‘... ECHO point then Santa Maria.” The report also suggested engineer and that all other radio communication had been made
that the similarity between the Selcal (Echo Mike Alpha Lima) by the first officer.
Simultaneously, as “ah” was uttered by the first officer, a voice At 1407:57, the first officer offered to help but the captain
in the background said, “Make it three.” The report said the said, “No.”
voice was “not identifiable, probably the captain.”
At 1408:00, the report said that flight data recorder (FDR)
At 1357:05, the first officer keyed the mike and transmitted: information showed “a sudden drop from 1,751 feet [534
“One zero two seven.” This was the final radio transmission meters] followed by a sudden climb to 1,869 feet [570 meters],”
from IDN 1851 recorded on the ATS tape and the only readback which was caused by the turbulence.
the tower received.
At approximately 1408, the radio altimeter began to whine,
The report concluded that the tower controller and the first followed by the GPWS alarm as the aircraft began to climb
officer made simultaneous transmissions. Thus, the crew did [because of turbulence], but the report said that there was no
not receive a complete clearance and the trainee controller did reaction on the part of the flight crew.
not receive a complete readback of the clearance.
“The GPWS sounded its ... alarm for seven seconds, alerting
In the cockpit, the first officer questioned aloud the QNH value, the crew of a potentially dangerous situation. Strangely, the
but the captain agreed that the first officer had correctly crew did not make any comment or try to remove this aircraft
understood the controller. from this situation ... ,” the report said.
The report said that after being cleared for the ILS approach “It must be pointed out that the crew had sufficient time to try
at 1356:47, “the crew failed to accomplish an approach to take the aircraft from this situation because the [median]
briefing, which would have included a review of the approach reaction time to a GPWS alarm is about 5.4 seconds according
plate and minimum safe altitude. If the approach plate had been to information from several airlines,” the report said.
properly studied, they certainly would have noticed that the
minimum safe altitude was 3,000 feet and not 2,000 feet, as it At 1408:12, the aircraft was level when it impacted the ridge
had been understood, and they would have noticed the existence of the mountain (Figure 2, page 14).
and elevation of Pico Alto, clearly marked on the chart ... .”
According to the report, the aircraft collided with a rock wall
The report added that under ICAO’s “Rules of the Air and Air on the side of a road at the mountain top. The impact, at an
Traffic Services, Part II,” the procedures “do not relieve the altitude of approximately 1,795 feet (547 meters) AGL, was
pilot of his responsibilities to ensure that any clearance that is so close to the pinnacle of Pico Alto that most of the wreckage
received from Air Traffic Control is safe in this regard, except was found on the western slope.
when under IFR radar vectors, which was not the case [in this
accident].” [Underline emphasis is in the original report.] The aircraft sliced at eye level through trees with diameters of
1.17 inches to 1.56 inches (30 centimeters to 40 centimeters),
The report also noted that company procedure required that which were found “covered with human remains, clothes and
“after receiving and reading back a clearance with ATC, the pieces of the aircraft hanging on the branches.” The fuselage
hands-on pilot, in this case the captain, should repeat loud and was completely destroyed, and sections of the wings were
clear his understanding of the clearance so that all the crew scattered around the western side of the peak. Flaps and landing
will be aware of its contents, namely the sector altitude.” gear had apparently been retracted at the time of the accident.
At 1402, the flight was 25 nm from the point of impact, and Most of the wreckage of the engines was found on the eastern
passing 6,500 feet (1,981 meters) in light turbulence at 260 slope, and the report indicated that engines 2, 3 and 4 had hit
knots indicated air speed (KIAS). the wall. Engine 1 had “crashed into the [eastern] slope,
between five and seven meters [16.4 feet and 22.9 feet] from
At 1403, the first officer said, “Ah after two thousand yeah the top, and continuing its way on the [western] slope.”
we’ll get below these clouds.”
Investigators recovered from the aircraft wreckage two
At 1406, the flight was 7.5 nm from the point of impact, and altimeters and the altitude alerter. Although the instruments
beginning to level at 2,000 feet (610 meters) in light turbulence were severely damaged, investigators were able to determine
at 250 KIAS. that one altimeter was set to 1028 millibars and the other
ALT – Altitude
WHOOP WHOOP – PULL UP KIAS – Knots indicated airspeed
WHOOP WHOOP – PULL UP HDG – Heading
WHOOP WHOOP – PULL UP
WHOOP WHOOP – PULL UP
WHOOP WHOOP – PULL UP
WHOOP WHOOP [CRASH]
ALT – 1387´
KIAS – 208
HDG – 252°
ALT – 1447´
KIAS – 208
HDG – 252°
Time
14 08 3.1
14 08 0.1
14 08 12
14 08 8.2
14 08 6.3
14 07 45.6
14 07 53
14 08
Figure 1
A – Indicated altitute 3,000 feet (914 meters) with altimeter set at C – Indicated altitute 2,000 feet (610 meters) with altimeter set at
1018 hPa 1018 hPa
B – Indicated altitude 3,000 feet (914 meters) with altimeter set at D – Indicated altitude 2,000 feet (610 meters) with altimeter set at
1027 hPa 1027 hPa
Figure 2
2. “Deficient communications technique on the part of the least known by one of the crew members, and also to
first officer who started his readback of the descent the low-altitude terrain warning sound alarms;
clearance to 3,000 feet given by the tower before the
tower finished its transmission; 6. “[Nonadherence] to the standard phraseology either by
flight crew or by the air traffic controllers in some of
3. “Violation by the airport control tower when it did not the air-ground communications;
require a complete readback of the descent clearance;
7. “Reduced experience of the crew in international flights,
4. “[Nonadherence] by the crew to the procedures namely the first officer;
established in the appropriate company manuals, namely
with respect to cockpit discipline, approach briefing, 8. “Deficient training of the flightcrew, namely concerning
repeating verbally of descent authorizations and informal the GPWS because it did not include emergency
conversations below 10,000 feet [3,048 meters]; maneuvers to avoid collision with the terrain;
5. “Generalized apathy of the crew concerning the errors 9. “Utilization of a [nonauthorized] route according to the
about the minimum altitude of the sector, which was at AIP-Portugal; [and,]
• Form a group with expertise in international operations Pedro Ferreira, who holds a U.S. commercial pilot certificate,
to assist air carrier inspectors to better monitor with multi-engine and instrument ratings, translated the
international airline operations; Portuguese report into English. The translation was edited for
accuracy by Col. Joao Letras, air attache, at the Portuguese
• Publish guidance to air carriers on international safety Embassy in Washington, D.C.
factors;
The FAA’s Aviation Safety Action Plan, a product of the special
• Periodically review international air carrier operating aviation safety summit called in January 1995 by the U.S.
procedures training programs to verify that they Department of Transportation Secretary Federico Peña,
adequately address safety factors; includes a number of initiatives that relate to some of the
circumstances of this accident.
• Review Part 121 and Part 135 air carriers’ training
programs and FAA-approved manuals to ensure GPWS • Minimal operational performance specifications have
terrain-avoidance training is adequate; been developed for equipment, and products are being
tested, to prevent blockage of ATC communications that
• Establish minimum crew pairing standards for are caused by stuck microphones and simultaneous
international operations and prohibit operations unless communications;
they are met; and,
• Standards will be proposed to ICAO, regarding use and
• Encourage pilots to report problems in international proficiency of spoken English. (No ICAO standard
operations to the U.S. National Aeronautics and Space currently exists to identify English as the official
Administration’s (NASA’s) Aviation Safety Reporting international language of ATC.);
System (ASRS) program.
• Differences between ICAO phraseology and U.S.
The Inquiry Commission made the following recommendations: phraseology must be identified, and pilots must be made
aware of any country’s differences from ICAO
• Determine the proper minimum altitudes based on the phraseology; and,
height of the [television] antenna;
• A user-friendly pamphlet should be developed to explain
• Correct entry point names in accordance with ICAO rules; commonly used phrases and clearances by controllers
and pilots to ensure common understanding and/or a
• Publish a NOTAM [notice to airmen] concerning the basis for knowing the other party’s intentions and
restricted use of the [Santa Maria] VOR; expectations.
• Publish an updated WAC [world aeronautical chart] for Capt. Thomas A. Duke piloted Independent Air 1851 into
Santa Maria; Bergamo the morning of the accident in Santa Maria. He has
more than 11,400 hours in military and civilian aircraft. He
• Review and correct the procedures regarding using the flew four-engine transports in the 1960s, and from 1977 to
[Santa Maria] VOR for airways use at Santa Maria; and, 1983 Duke was director of safety of the U.S. Air Force Reserve.
He has more than 15 years experience as an accident
• Revise METARs to comply with ICAO guidance on investigator and flight safety officer. Duke also was a
altimeter settings.♦ researcher for the U.S. National Transportation Safety Board.
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