Incident Overview

Date: Wednesday 9 August 1995
Aircraft Type: Boeing 737-2H6
Owner/operator: Aviateca
Registration Number: N125GU
Location: 24 km NE of San Salvador – ÿ El Salvador
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 65 / Occupants: 65
Component Affected: Boeing 737Boeing 737
Investigating Agency: AAC El SalvadorAAC El Salvador
Category: Accident
On Flight GUG901, a Boeing 737 deviated from Airway G346 to avoid severe thunderstorms approaching San Salvador. The aircraft then turned right downwind for an ILS approach to runway 07. A lack of situational awareness among the flight crew, including descent below the Minimum Safe Altitude (MSA), resulted in a collision with the San Vicente Volcano at an altitude of 1800 meters. The incident highlights a failure of the flight crew, controller, and Aviateca’s CRM program.On Flight GUG901, a Boeing 737 deviated from Airway G346 to avoid severe thunderstorms approaching San Salvador. The aircraft then turned right downwind for an ILS approach to runway 07. A lack of situational awareness among the flight crew, including descent below the Minimum Safe Altitude (MSA), resulted in a collision with the San Vicente Volcano at an altitude of 1800 meters. The incident highlights a failure of the flight crew, controller, and Aviateca’s CRM program.

Description

Flight GUG901 (Miami-Guatemala City-San Salvador-Managua-San Jose) encountered bad weather (heavy rain, thunderstorms) while approaching San Salvador. The crew therefore diverted off Airway G346 to avoid the thunderstorms. The aircraft should then have passed overhead the airport and turn right downwind for an ILS approach to runway 07. There seemed to be some confusion as to the position of the aircraft. The aircraft was at 5000 feet (as cleared by ATC) when the GPWS sounded. Full power was applied, but the Boeing struck the San Vicente Volcano (also known as Chinchontepec, 2181 m high) at an altitude of 1800 m. PROBABLE CAUSE: “The Direccion General De Transporte Aereo determines that the probable cause of the accident was the flight crew’s lack of situational awareness in relation to the 7,159 foot obstruction, the flight crew’s decision to descend below the MSA while deviating from a published transition or approach, and the ambiguity of position information between both the flight crew and the air traffic controller which resulted in the controller’s issuance of an altitude assignment that did not provide terrain clearance. Contributing to the accident was the failure of the First Officer to direct his concern of reported positions to the Captain in a more direct and assertive manner and the failure of the controller to recognize the aircraft’s reported position relative to obstructions and give appropriate instructions/warnings. An ineffective CRM program at Aviateca also contributed to the accident .”

Primary Cause

The flight crew’s lack of situational awareness regarding the 7,159-foot obstruction, the decision to descend below the MSA while deviating from a published transition or approach, and the ambiguity of position information between the flight crew and the air traffic controller, leading to an altitude assignment that did not provide terrain clearance.The flight crew’s lack of situational awareness regarding the 7,159-foot obstruction, the decision to descend below the MSA while deviating from a published transition or approach, and the ambiguity of position information between the flight crew and the air traffic controller, leading to an altitude assignment that did not provide terrain clearance.

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