Aircraft Accident Brief
Controlled Flight Into Terrain
CASA C-212-CC, N960BW
Bamiyan, Afghanistan
November 27, 2004
NTSB/AAB-06/07
PDF Document [823 KB]
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Accident Number: |
IAD05FA023 |
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Aircraft and Registration: |
CASA C-212-CC, N960BW |
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Location: |
Bamiyan,
Afghanistan |
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Date: |
November
27, 2004 |
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Adopted On: |
November 8, 2006 |
HISTORY OF FLIGHT On November
27, 2004, about 0820 Afghanistan time, 1 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 (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 cargo 4 to Farah, Afghanistan
(OAFR), and the three military passengers were traveling in a “space
available” status. 5 The flight was to depart
OAIX and fly to OAFR, and then fly to Shindand, Afghanistan (OASD),
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 (OAKN), 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 (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 feet 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 nm 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 (see figure 1). 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 mechanic 8 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 feet 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 180º 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 accident site was approximately 80 nm west of OAIX
and approximately 25 nm north of the operator’s typical route between
OAIX and OAFR. The operator was notified by military personnel, about
1415, that the airplane had never arrived at OAFR. Search and rescue
operations were initiated by the military about 1540, and the wreckage
was located on November 28, 2004, about 0815. First responders who
arrived at the accident site on November 30, 2004, reported evidence
that one passenger had exited and re-entered the wreckage before he
died (see Survival Aspects section). PERSONNEL INFORMATION The Captain The
captain, age 37, held an airline transport pilot certificate with
a rating for airplane multi-engine land and type ratings for “CA-212,”
“CE-500,” “EMB-110,” and “SA-227” airplanes. 10
He also held commercial privileges for airplane single-engine land
and airplane single-engine sea. His most recent Federal Aviation Administration
(FAA) first-class airman medical certificate was dated October 1,
2004, with the limitation, “must wear corrective lenses.” The
captain was hired by Presidential Airways on October 1, 2004. According
to his résumé, the captain reported 5,720 total flight hours, which
included 4,930 hours pilot-in-command (PIC) with 685 hours PIC in
CASA 212 airplanes. According to an insurance application dated September
23, 2004, the captain reported 865 hours in CASA 212 airplanes. The
director of operations of Presidential Airways reported that, during
the captain’s employment interview, he stated he had “harsh environment”
operating experience and had flown extensively throughout the northwestern
United States and Alaska. The director of operations stated he verified
this information with the two previous employers listed on the captain’s
résumé. The
captain began company indoctrination training with six other pilots,
including the first officer, on October 1, 2004. He completed the
indoctrination training on October 5, 2004, and began aircraft-specific
training in CASA 212 airplanes, which he completed on October 9, 2004.
On November 2, 2004, the captain passed an Airman Competency/Proficiency
Check in a CASA 212 airplane in accordance with 14 CFR 135.293, “Initial
and recurrent pilot testing requirements,” paragraphs (a) and (b);
14 CFR 135.297, “Pilot in command: Instrument proficiency check requirements”;
and 14 CFR 135.299, “Pilot in command: Line check: Routes and airports.” The
captain arrived in Afghanistan on November 14, 2004, and the next
day he flew a 6.3-hour theater-indoctrination flight with a company
pilot who had experience with flying in Afghanistan. The flight included
stops at OAIX; OAKN; Herat, Afghanistan (OAHR); and OASD. Records
provided by the operator indicated the captain flew six subsequent
missions in Afghanistan with, at least, one flight into OAFR. The
captain accumulated a total of 32.3 hours in Afghanistan, which included
23.5 hours in CASA 212 airplanes. According to the operator, in the
90 and 30 days prior to the accident, the captain had accumulated
87.8 and 65.9 total flight hours, respectively. According
to Presidential Airways’ program site manager, the captain’s last
flight prior to the accident flight ended at 1130 on November 24,
2004. Four company pilots who lived in the same
quarters with the captain reported that, in the 72 hours before the
accident, the captain appeared well rested, had a good attitude, and
ate regular meals. The program site manager estimated the captain
smoked about two cigarettes per day. Two company pilots stated that,
on the morning of the accident, the captain told them he had a sore
or scratchy throat, and he thought he might be coming down with a
cold. Both pilots stated they offered to fly for the captain, but
the captain declined. A
review of FAA airman records revealed that, on February 10, 1997,
the captain was issued a notice of disapproval of application for
an airline transport pilot certificate. He subsequently completed
the requirements and was issued an airline transport pilot certificate
on March 7, 1997. A
review of Presidential Airways’ records revealed the captain reported
he had never been convicted of reckless driving or of driving a motor
vehicle under the influence, and his driver’s license had never been
suspended or revoked. The First Officer The first officer, age 35, held an airline transport pilot
certificate with a rating for airplane multi-engine land and commercial
privileges for airplane single-engine land. His most recent FAA first-class airman medical certificate was dated January
28, 2004, with no waivers or limitations. The first officer was hired by Presidential Airways on
October 1, 2004. According to his résumé, the first officer reported 2,228 total flight
hours, which included 1,248 hours in multi-engine airplanes. According
to an insurance application, dated September 23, 2004, the first officer
reported 917 hours PIC and 420 hours in CASA 212 airplanes. The first officer began company indoctrination training
with six other pilots on October 1, 2004. He completed
the indoctrination training on October 5, 2004, and began aircraft-specific
training in CASA 212 airplanes, which he completed on October 9, 2004.
On October 10, 2004, the first officer and another captain
ferried a CASA 212 airplane from Alaska to Florida. On October 13,
2004, the first officer passed an Airman Competency/Proficiency
Check in a CASA 212 airplane, in accordance with 14 CFR 135.293, “Initial
and recurrent pilot testing requirements,” paragraphs (a) and (b),
and 14 CFR 135.299, “Pilot in command: Line checks: Routes and airports.” The
first officer arrived in Afghanistan on November 14, 2004, and, the
next day, he flew a 4.8-hour theater-indoctrination flight with a
captain who was experienced flying in Afghanistan. The flight included
stops at OAIX; Salam, Afghanistan; and Jalalabad, Afghanistan. Records
provided by the operator indicated the first officer flew five subsequent
missions in Afghanistan with, at least, one flight into OAFR. The
first officer accumulated a total of 29.6 hours in Afghanistan, which
included 23.4 hours in CASA 212 airplanes. According to the operator,
in the 90 and 30 days prior to the accident, the first officer had
accumulated a total of 67 and 65.2 flight hours, respectively. According
to the operator’s program site manager, the first officer’s last flight
prior to the accident flight ended at 1130 on November 24, 2004. Four
company pilots who lived in the same quarters with the first officer
reported that, in the 72 hours before the accident, the first officer
appeared well rested, had a good attitude, and ate regular meals. A
company captain stated he had flown with the first officer during
the previous three summers on firefighting support flights to drop
smokejumpers and para-cargo 11 to fight wildfires.
He described the first officer as a knowledgeable and skilled pilot
who was experienced with mountain flying and low-altitude missions. A
review of FAA airman records revealed
on July 9, 1991, the first officer was issued a notice of disapproval
of application for a private pilot certificate. He subsequently completed
the requirements and was issued a private pilot certificate on July
18, 1991. He was issued a notice of disapproval of application for
a commercial pilot certificate on September 12, 1995. He subsequently
completed the requirements and was issued a commercial pilot certificate
on September 13, 1995. On October 16, 2002, he was issued a notice
of disapproval of application for an airline transport pilot certificate.
He was issued a second disapproval on October 21, 2002. He subsequently
completed the requirements and was issued an airline transport pilot
certificate on October 22, 2002. A
review of Presidential Airways’ records revealed the first officer
reported he had never been convicted of reckless driving or of driving
a motor vehicle under the influence, and his driver’s license had
never been suspended or revoked. AIRCRAFT INFORMATION The CASA 212 was an unpressurized, high-wing airplane with fixed landing gear, a rear ramp-type cargo door, and a maximum gross weight of 16,976 pounds (lbs). It was configured with nine seats. The airplane was powered by two Garrett TPE331-10R-511C, 900-shaft-horsepower engines, each equipped with a Hartzell constant-speed, four-blade propeller with full-feathering and reverse-pitch capabilities. The instrument panel was equipped with an Apollo GX- 50 GPS. The cockpit was equipped with quick-donning oxygen masks for the captain and the first officer. The passenger oxygen masks and equipment were carried in a case and could be plugged into a console in the passenger area when their use was required. The airplane’s emergency locator transmitter
(ELT) was an Artex model 110-4, which was designed to transmit a 121.5-megahertz
(MHz) signal automatically when subjected to certain forces, such
as those sustained during an impact. According
to weight and balance calculations, the airplane weighed approximately
15,664 lbs at takeoff and had a predicted landing weight of 13,714
lbs. The center of gravity (CG) at takeoff was calculated as 19.1
percent of mean aerodynamic chord (MAC), and the predicted landing
CG was 17.5 percent of MAC. According to the airplane flight manual
(AFM), the airplane’s maximum permitted takeoff weight was 16,976
lbs, the forward CG limit for the calculated takeoff weight was about
16 percent of MAC, and the aft limit was about 30 percent of MAC.
On the basis of these data, the airplane would have remained within
operational limits during the entire accident flight. The stall speed of the airplane
is affected by flap configuration and wing bank angle. As the airplane’s
flap angle increases (that is, as flaps are lowered), stall speed
decreases. As the airplane’s wing bank angle increases (to turn in
level flight), stall speed increases. Based on AFM performance charts,
the approximate stall speeds for the airplane, in knots (kts) of
calibrated airspeed in various bank angle and flap configurations,
are shown in figure 2. According
to the AFM’s “Balked Landing Rate of Climb - Two Engine Operation”
chart, at 14,000-feet pressure altitude, -8º Celsius, and an aircraft
weight of 15,000 lbs, the climb rate would be about 690 feet per minute
(fpm) with full flaps, takeoff power, and an airspeed of 83 kts. A review of maintenance records indicated that, at the
time the airplane departed on the accident flight, it had accumulated
21,489.6 total hours. The No. 1 engine had accumulated 11,087.3 hours
since new and 363.6 hours since overhaul, and the No. 2 engine had
accumulated 7,327.1 hours since new and 908.3 hours since overhaul.
The airplane received its 1A and 2A inspections, 12 in
accordance with the manufacturer’s guidelines, on November 25, 2004,
and had accumulated 4.2 hours since the inspections. METEOROLOGICAL INFORMATION A weather observation taken about 0725 at OAIX, elevation
4,895 feet, recorded wind variable at 4 kts, unrestricted visibility,
few clouds at 8,000 feet and 20,000 feet, temperature 39º Fahrenheit,
dew point 28º Fahrenheit, and altimeter setting 30.35 inches
of mercury. A weather forecast briefing prepared by the military at
0600 for an area that included the flight route predicted winds aloft
from 240º at 20 kts, at 9,000 feet and 10,000 feet. The forecast predicted
no visibility restrictions, thunderstorms, turbulence, icing, or precipitation
aloft. Surface conditions at OASD, elevation 3,773 feet, from 1100
to 1200, were predicted to include winds from 180º at 15 kts gusting
to 25 kts and 3 statute miles visibility in blowing dust. Another Presidential Airways crew departed OAIX in a CASA
212 airplane about the same time as the accident flight, but their
flight was en route to a different destination, OAHR. The typical
route to that crew’s destination did include flight along the Bamiyan
Valley, and the captain of that flight stated he flew within about
5 nm of the accident site. He stated that he flew at 12,500 feet
msl and observed the wind was from the southwest at 5 to 10 kts. He
stated that he observed a scattered to broken cloud layer at 13,000
feet msl and that the cloud layer had a maximum thickness of 500 feet
but was predominantly about 200 feet thick with cloud caps just above
the individual mountain peaks. He estimated that there was a minimum
of 10 miles of visibility in haze. FLIGHT RECORDERS The airplane’s Fairchild model 100A CVR was examined at the National Transportation Safety Board, Vehicle Recorders Division, Washington, D.C. The exterior of the CVR was damaged, but the tape inside sustained little damage. The CVR recording consisted of four channels of good quality 13 audio information. One channel captured the audio from the captain’s panel, another captured the audio from the first officer’s panel, and a third captured the audio from the CAM; the fourth CVR channel was unused. The CVR captured the last 32 minutes of the flight, and the recording captured no radio communications between the flight crew and any air traffic control facilities. The review of voice recordings from the captain, the first officer, and the mechanic revealed no evidence of sounds consistent with oxygen mask use. The airplane was not equipped, and was not required to be equipped, with a flight data recorder. 14 WRECKAGE AND IMPACT INFORMATION The wreckage was at an elevation of approximately 14,650 msl in a box canyon that was bounded on the east and west by 15,000-foot ridgelines and terminated at a 16,580-foot peak to the south. The northern end of the box canyon opened to the Bamiyan Valley, where the floor of the canyon was approximately 11,000 feet msl; the floor of the box canyon rose from north to south to its terminus. The terrain was rocky, snow-covered, and void of trees and vegetation. The Safety Board’s accident investigation team did not
travel to the accident site. The first military recovery team to access
the site arrived on board a Boeing CH-47 helicopter, and the recovery
team estimated that about 20 inches of snow had fallen since the accident
3 days earlier. The CH-47 was hovered over the site for about 10 minutes
in order to use its rotor wash to blow away the snow. Review of photographs
and information provided by the military showed the wreckage was located
on the northern face of an area of rising terrain. According to military
first responders, the airplane was on its left side at the northeast
end of a wreckage and cargo debris path that extended approximately
450 feet. The responders reported that the rear cargo ramp was separated
and on the ground adjacent to the empennage, the right wing and right
engine were separated, and the left wing was crushed under the fuselage.
Wing flap configuration was not determined. The CVR was the only wreckage
component recovered for examination. The first responders reported that they observed no evidence
that the captain or the first officer had used their oxygen masks
and that the oxygen equipment for the passengers was found in an unopened
case. MEDICAL AND PATHOLOGICAL INFORMATION Toxicological
examinations of specimens from the captain and the first officer were
performed by the Armed Forces Institute of Pathology, Washington,
D.C. No evidence of alcohol or performance-impairing drugs was found. The
Office of the Armed Forces Medical Examiner, Dover Air Force Base
Port Mortuary, Dover, Delaware, performed autopsies on all six occupants
of the airplane on December 3, 2004. The autopsy reports stated the
cause of death for the captain, the first officer, the mechanic-certificated
passenger, and two of the active-duty military passengers was “blunt
force injuries.” The autopsy report for the third active-duty military
passenger stated the cause of death was “blunt force injuries of the
torso complicated by hypoxia and hypothermia.” The Safety Board reviewed
the autopsy findings regarding the passenger’s internal injuries and
examined a photograph of a specific internal injury.15
SURVIVAL ASPECTS Passenger with Survivable Injuries Military
first responders who arrived at the accident site observed a body,
later identified as the active-duty military passenger who died of
injuries complicated by hypoxia and hypothermia, lying prone inside
the rear cargo area of the wreckage. The body was oriented with the
head toward the front of fuselage, and the clothing consisted of pants
and shoes. In close proximity to the body were an unrolled sleeping
bag, a cigarette butt, and a half-empty water bladder from a Camelbak
hydration system. An open box of Meals Ready-to-Eat was also inside
the fuselage, but responders could not determine if it had been opened
before or after the accident. Outside
the wreckage, an empty cigarette package was observed on the ground
near the fuselage, and two frozen urine stains were observed in the
snow, one near the front of the fuselage and one near the rear cargo
ramp. A metal ladder was leaning against the fuselage in such a way
that, according to first responders, it appeared to have been deliberately
positioned to enable a person to climb on top of the wreckage. First
responders also reported that a wooden pallet on top of the rear cargo
ramp appeared to have been placed there. An opened Swiss Army daypack
was found on the ground near the fuselage, and underneath it were
maps and a pilot’s checklist. Notification of the Overdue Airplane According to the operator’s program site manager at OAIX,
the airplane’s estimated time of arrival at OAFR was 0955, and it
was due back at OAIX about 1345. Military personnel notified the program
site manager about 1415 that the airplane had never arrived at OAFR,
which was about 30 minutes after its expected return time at
OAIX. According to the DoD contract, the flight crews were required to report their arrivals at remote loc |
