Incident Overview

Date: Thursday 17 January 2002
Aircraft Type: Fairchild FH-227E
Owner/operator: Petroproduccion – Unidad de Aviacion
Registration Number: HC-AYM
Location: Cerro El Tigre – ÿ Colombia
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 26 / Occupants: 26
Component Affected: Aircraft Control System (specifically, the lack of CRM, human factors, and CFIT training)Aircraft Control System (specifically, the lack of CRM, human factors, and CFIT training)
Investigating Agency: DGAC EcuadorDGAC Ecuador
Category: Accident
A FH-227 aircraft experienced a near-miss flight near Lago Agrio in the Amazon jungle, resulting in a descent into fog-shrouded terrain. The flight was conducted at 15,500 feet with a VFR flight and weather conditions including a 6 knot wind and 29øC temperature. The crew reported near Olmedo and then failed to execute a turn to Lago Agrio, leading to a prolonged descent. The aircraft ultimately impacted the side of El Tigre Mountain at 11,916 feet, and the investigation suggests a loss of situational awareness due to distractions, lack of training, and inadequate support.A FH-227 aircraft experienced a near-miss flight near Lago Agrio in the Amazon jungle, resulting in a descent into fog-shrouded terrain. The flight was conducted at 15,500 feet with a VFR flight and weather conditions including a 6 knot wind and 29øC temperature. The crew reported near Olmedo and then failed to execute a turn to Lago Agrio, leading to a prolonged descent. The aircraft ultimately impacted the side of El Tigre Mountain at 11,916 feet, and the investigation suggests a loss of situational awareness due to distractions, lack of training, and inadequate support.

Description

The FH-227 departed Quito at 10:38 for a 37-minute flight to fly workers to an oil site in the Amazon jungle. The VFR flight was conducted at an altitude of 15,500 feet. At 10:50 the crew contacted the Nueva Loja Tower at Lago Agrio and reported near Olmedo. The Tower controller reported that runway 23 was in use and that the weather included a 6 knot wind at 020 degrees, temperature 29 degrees. The crew were then to have turned from 064 to 094 degrees, direct to Lago Agrio. They failed to do so and continued their present heading. After reporting 50 miles out at 10:59, they were cleared to descend. This was the last contact with the flight. The crew continued their descent until the airplane flew into the fog-shrouded side of El Tigre Mountain at an elevation of 11,916 feet. PROBABLE CAUSE (translated from Spanish): “The Accident Investigative Board estimates that the probable cause of the accident was LOSS OF SITUATIONAL AWARENESS by the crew, since their attention was focused on aspects that were not related to the flight being executed and therefore neglecting the primary function of flight which is the control of the aircraft and decision making. CONTRIBUTING FACTORS: – Crew failure to maintain a sterile cockpit – The continuous distraction of the crew throughout the flight – The lack of technical documentation in the CIA that supports the operation. – Lack of crew training in CRM, human factors and CFIT – The weather conditions at the time of the accident on Mount El Tigre made it impossible for the crew to see the mountain. – The lack of defence systems on the aircraft (GPWS ground proximity warning system)

Primary Cause

Loss of situational awareness due to distractions, lack of training, and inadequate support.Loss of situational awareness due to distractions, lack of training, and inadequate support.

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