Incident Overview

Date: Monday 9 August 1954
Aircraft Type: Lockheed L-749A-79 Constellation
Owner/operator: Avianca
Registration Number: HK-163
Location: 9 km WSW of Terceira-Lajes Airport, Azores (TER) – ÿ Portugal
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 30 / Occupants: 30
Component Affected: Pilot’s actions and navigation ? specifically the turn to the left and failure to execute the climb-out procedure.Pilot’s actions and navigation ? specifically the turn to the left and failure to execute the climb-out procedure.
Category: Accident
On 02:40, a Constellation crashed into high ground near Monte de Boi on Lajes Island following a diversion to Lajes Airport on Terceira Island, heading for Bermuda. The flight left the runway around 34, and the aircraft experienced a loss of control, resulting in a crash. The pilot?s actions ? a turn to the left instead of right, and failure to execute the climb-out procedure ? contributed to the incident. The chart indicated a turn towards the Northeast, and the pilot?s intention was to proceed to Ponto Sul, a point marked on the chart, which is located on the island?s extreme northeast. The aircraft?s navigation error, combined with the terrain surrounding Monte de Boi, led to the crash.On 02:40, a Constellation crashed into high ground near Monte de Boi on Lajes Island following a diversion to Lajes Airport on Terceira Island, heading for Bermuda. The flight left the runway around 34, and the aircraft experienced a loss of control, resulting in a crash. The pilot?s actions ? a turn to the left instead of right, and failure to execute the climb-out procedure ? contributed to the incident. The chart indicated a turn towards the Northeast, and the pilot?s intention was to proceed to Ponto Sul, a point marked on the chart, which is located on the island?s extreme northeast. The aircraft?s navigation error, combined with the terrain surrounding Monte de Boi, led to the crash.

Description

Bad weather conditions at destination Santa Maria, Azores, forced the crew to divert to Lajes Airport on Terceira Island. Heading for Bermuda, the flight left Lajes’ runway 34 around 02:40. Three minutes after takeoff, the Constellation crashed into high ground near the Monte de Boi at 620 m. PROBABLE CAUSE: “The failure of the pilot to carry out the normal climb out procedure following takeoff from runway 34 on a flight to Bermuda and his having made a turn to the left instead of to the right, thus flying into the mountains instead of turning out to sea. The possibility of the aircraft having been forced to make a left turn may be disregarded since, from examination of the wreckage, it appears that no mechanical failure occurred. The procedure to be followed had been duly explained to the crew both at the briefing and in the instructions which were certainly given by the tower. It is pointed out, moreover, that the chart of Lajes in the route manual supplied to the crew clearly shows that all turns must be made towards the Northeast. The question of a right turn following take-off appears to have been deemed a secondary matter by the crew members who called at the briefing office. They simply established that they had to proceed directly to Ponto Sul in order to avoid a collision with the mountains, the highest point of which reached 7615 feet. From the heading presumed to have been flown by the aircraft before it crashed, it is apparent that the pilot did, in fact, intend to proceed to Ponto Sul. He appears not to have realized, however, that to do so he had to turn eastward towards the sea and not to the West over the land. It is necessary to mention that, according to his company, this was the first time that the captain had landed at Lajes and that at Santa Maria, where he had already landed several times, the take-off procedure for flights towards the Northwest in the direction of Bermuda also involves a turn towards the sea. The turn at Santa Maria. is made to the left, however, as the airport is located on the extreme west of the island. The point known as Ponto Sul is shown on the reproduced 1:1 000 000 chart at Fig. 30. Examination of this chart will immediately explain the reason for the adoption in the Azores -control area of the standard procedure whereby aircraft are required to fly over this point before proceeding towards Bermuda, in order to avoid the high ground on Terceira, S. Jorge, Pico and Faial Islands. Since Lajes Airport is located in the extreme Northeast of the Ilha Terceira, the requirement, for reasons of safety, to turn to the east and out to sea in order to avoid the mountains on the island needs no special comment, being obvious in view of the nature of the terrain.

Primary Cause

Pilot error ? failure to execute the climb-out procedure and turn to the right, resulting in a left turn into the mountains instead of continuing towards the sea.Pilot error ? failure to execute the climb-out procedure and turn to the right, resulting in a left turn into the mountains instead of continuing towards the sea.

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