C212, en-route, Bamiyan Afghanistan, 2004
From SKYbrary Wiki
|On 27 November 2004, a CASA C212 operated by Presidential Airways, crashed in moutainous terrain near Bamiyan, Afghanistan. The aircraft stalled while trying to climb over a ridge.|
|Actual or Potential
|Human Factors, Loss of Control|
|Aircraft||CASA C-212 Aviocar|
|Type of Flight||Military/State|
|Intended Destination||Farah Airport|
|Take off Commenced||Yes|
|Approx.||near Bamiyan, Afghanistan|
|Tag(s)||Inadequate Aircraft Operator Procedures|
Procedural non compliance,
|Tag(s)||Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.|
|Damage or injury||Yes|
|Aircraft damage||Hull loss|
|Fatalities||Most or all occupants ()|
|Causal Factor Group(s)|
On 27 November 2004, a CASA C212 operated by Presidential Airways, crashed in moutainous terrain near Bamiyan, Afghanistan. The aircraft stalled while trying to climb over a ridge.
"On November 27, 2004, about 0820 Afghanistan time, a Construcciones Aeronauticas Sociedad Anonima C-212-CC (CASA 212) twin-engine, turboprop airplane, N960BW,registered to Aviation Worldwide Services, LLC, and operated by Presidential Airways, Inc., of Melbourne, Florida, collided with mountainous terrain in the vicinity of the Bamiyan Valley, near Bamiyan, Afghanistan.2 The Department of Defense (DoD) contract flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135, with a company flight plan filed. Daylight visual meteorological conditions (Visual Meteorological Conditions (VMC)) prevailed. The captain, the first officer, and the mechanic-certificated passenger, who were U.S. civilians employed by the operator, and the three military passengers, who were active-duty U.S. Army soldiers, received fatal injuries. The airplane was destroyed. The flight departed Bagram Air Base (OAIX), Bagram, Afghanistan, about 0738."
"Presidential Airways provided transport services for U.S. military personnel and cargo within Afghanistan, Uzbekistan, and Pakistan under an Air Mobility Command (AMC) contract with the DoD.3 According to Presidential Airways’ program site manager, he briefed the captain on the mission itinerary about 0700. The purpose of the mission was to transport military cargo4 to Farah, Afghanistan (OAFR), and the three military passengers were traveling in a “space available” status. The flight was to depart OAIX and fly to OAFR, and then fly to Shindand, Afghanistan (Shindand Airbase), for fuel before returning to OAIX. The briefing included the expected cargo and passenger loads, as well as military intelligence information that there were no significant threats for the mission. The program site manager and the captain discussed the area weather forecast, which primarily consisted of VMC with the possibility of blowing dust at OASD, and they agreed that Kandahar, Afghanistan (Kandahar International Airport), would be an appropriate alternate destination if the flight were unable to land at OASD. According to the program site manager, he was not aware if route planning was performed for the mission. The accepted visual flight rules (Visual Flight Rules (VFR)) flight plan contained destination information but did not indicate the specific route of the flight. The program site manager stated he assumed the crews followed certain typical routes between destinations; the pilots were to fly the routes “GPS [global positioning system] direct” while maintaining flight in VMC and clearance from terrain. According to OAIX air traffic control transcripts, during initial radio contact with the ground controller, the crew announced an intended flight altitude of 10,000 ft3,048 m
mean sea level (msl) and a departure heading to the south; this departure heading was consistent with the operator’s typical route from OAIX to OAFR, which involved a departure and flight to the south for approximately 32 nautical miles (nm) to avoid the mountains west of OAIX, then a turn to the west direct to OAFR. The crew taxied the airplane for takeoff but then stopped it briefly on the taxiway and boarded an additional passenger.6 The controller then cleared the flight for takeoff from runway 3, and the flight departed. At 0738, the OAIX controller instructed the crew to contact the departure controller, and the crew acknowledged. There was no record of radio communication between the flight crew and the departure controller, and no further known radio communication was received from the flight. A review of ground-based radar data revealed the airplane did not depart on the southerly heading but, instead, departed to the northwest. Radar contact was lost approximately 9.5 nm17,594 m
northwest of OAIX, consistent with the normal expected limit of radar coverage for the area. The last recorded radar position showed the flight on a westerly heading at an approximate altitude of 10,000 feet msl; the position and heading were consistent with the flight entering the Bamiyan Valley."
"The cockpit voice recorder (CVR) recording began about 0748:37.7 The flight was airborne, and the first officer stated, “cruise check is complete.” Initial conversation indicated that the crew had never flown the selected route to OAFR and the mechanic8 noted that the valley they had chosen to fly through was not the direct route to OAFR. At 0753:28, the captain stated, “we’ll just have to see where this leads.” The CVR then recorded the captain, the first officer, and the mechanic discussing a topographical map, outside visual references, their current position coordinates (obtained from a GPS as they navigated), and their route over the mountains to OAFR. At 0756:12, the captain stated, “well normally we’d have time to on a short day like this we’d have time to play a little bit do some explorin’ but with those winds comin’ up I want to [expletive] get there as fast as we can.” At 0800:12, the captain stated, “with this good visibility … it’s as easy as pie. you run into somethin’ big you just parallel it until you find a way thru [sic]. … this is the first good visibility day I’ve had in the Casa. It’s not just good it’s outstanding.” An unidentified passenger asked about the route of flight at 0802:25, and the mechanic stated, “I don’t know what we’re gunna see, we don’t normally go this route.”9 The captain stated, “all we want is to avoid seeing rock at twelve o’clock.” At 0803:21, the first officer stated, “yeah you’re an x-wing fighter star wars man,” and the captain replied, “you’re [expletive] right. this is fun.” At 0803:34, the captain stated, “okay it’s about time we’re gunna start climbin’ … we’re comin’ up to a box up here. … yeah I think this valley might peter out right up here.” The first officer and the captain then discussed some of their previous mountain flying experiences. At 0812:45, the captain stated, “I swear to god they wouldn’t pay me if they knew how much fun this was,” and the first officer replied, “yeah, yeah, this is what we do flyin’ jumpers … we always do this. as low as we can get,” and the captain stated, “yeah that’s the way I use to do it.” At 0813:06, the captain added, “it takes an extraordinary day that you can actually get down in … and do some (expletive] like this.” At 0815:47, the first officer stated that the ridgeline off to their left had a minimum elevation of approximately 14,000 ft4,267.2 m
msl. The captain replied that he wanted to look for a notch to fly through. At 0818:26, the first officer stated, “boy it’s a good thing we’re not too heavy today I guess,” and the captain replied, “yeah oh I wouldn’t have done this if we were at gross. we can always turn around up in here.” At 0819:04, the mechanic asked, “okay you guys are gunna make this right?” The captain replied, “yeah h h [sic] I’m hopin’.” About 10 seconds later, the cockpit area microphone (CAM) recorded a sound similar to a stall warning tone single beep, and the mechanic immediately asked if there was a way out. At 0819:16, the captain stated they could execute a 180° turnaround, and he instructed the first officer to “drop a quarter flaps.” At 0819:25, the first officer stated, “yeah, let’s turn around,” and the captain again requested, “drop a quarter flaps.” The mechanic then stated, “You need to ah make a decision.” At 0819:44, the CAM recorded a sound similar to a stall warning that continued to the end of the recording. The mechanic stated, “call off his airspeed for him,” and the first officer stated, “you got ninety five.” Eight seconds after the first officer’s statement, the recording ended."
The reports conclusions include:
- "The flight crew flew a nonstandard route into a box canyon and did not take remedial action in a timely manner."
- "The flight crew did not use supplemental oxygen as required by Federal regulations for the altitudes at which the flight was operating."
- "The operator did not provide sufficient oversight of and guidance to it its flight crews."
and the probable cause of the accident was given as:
"The captain’s inappropriate decision to fly a nonstandard route and his failure to maintain adequate terrain clearance, which resulted in the inflight collision with mountainous terrain."
- Accident and Serious Incident Reports: LOC contains details of other accidents and incidents which resulted in, or might have resulted in, a Loss of Control.
- NTSB AAB-06/07: NTSB Aircraft Accident Brief IAD05FA023, CASA C-212, N960BW, November 27, 2004.
NTSB Safety Alerts on General Aviation risks