N960BW
CASA 212-200-CC
The Safety Board has adopted the final report of this accident investigation, including the analysis and probable cause. The Board's full report is available on: http://www.ntsb.gov/publictn/2006/AAB0607.pdf 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. 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.
------------ FACTUAL REPORT OF INVESTIGATION --------------- 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. 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 resume. 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 GX50 GPS. The cockpit was equipped with quick-donning oxygen masks for t
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. Factors were the operator's failure to require its flight crews to file and to fly a defined route of flight, the operator's failure to ensure that the flight crews adhered to company policies and FAA and DoD Federal safety regulations, and the lack of in-country oversight by the FAA and the DoD of the operator. Contributing to the death of one of the passengers was the operator's lack of flight-locating procedures and its failure to adequately mitigate the limited communications capability at remote sites. The Board's full report is available on: http://www.ntsb.gov/publictn/2006/AAB0607.pdf
Source: NTSB Aviation Accident Database
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