ASN Wikibase Occurrence # 230061
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| Date: | Saturday 19 October 2019 |
| Time: | 09:27 |
| Type: |  Cessna 172K Skyhawk |
| Owner/operator: | Escuela Centro de Adiestramiento Aéreo Avanzado – CAAA |
| Registration: | N7381G |
| MSN: | 17259081 |
| Year of manufacture: | 1970 |
| Fatalities: | Fatalities: 2 / Occupants: 4 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | San Cristóbal, El Progreso, El Boquerón -
 El Salvador
|
| Phase: | En route |
| Nature: | Private |
| Departure airport: | San Salvador/Ilopango International Airport (SAL/MSSS) |
| San Salvador/Ilopango International Airport (SAL/MSSS) | |
| Investigating agency: | AAC El Salvador |
| Confidence Rating: |  Accident investigation report completed and information captured |
A Cessna 172K Skyhawk impacted a mountainside in IMC. Two occupants died and two occupants were seriously injured.
Probable causes
1. The accident starts when, while flying under visual rules (VFR), the crew of N7381G enters a cloud cover (instrument meteorological conditions, or IMC), whereupon the pilots lose all visual reference, inducing in them an unrecognised spatial disorientation, making an inadvertent turn to the left and imperceptibly deviating 96° from the original course.
2. The loss of situational awareness on the part of the crew, by not notifying the Ilopango airport control tower that they were entering cloudy conditions and that they would be changing flight rules to instrument flight rules (IFR) and by not having adequate and constant monitoring of all navigation instruments during the time they remained in the aforementioned cloud cover. Constant monitoring of these would have warned the crew that they were making an unplanned turn to the left and that they were flying on a course that was not intended. From the time of the loss of course until the time of the accident, approximately 7 minutes elapsed during which no crew member noticed that N7381G was flying in the direction of the San Salvador volcano.
3. The complacency and excessive self-confidence of the crew, when starting a flight in which cloudy conditions were expected without GPS equipment (during the investigation it was found that the GPS equipment was on board the aircraft, however, the crew did not operate it at any time).
4. The complacency and lack of leadership of the pilot in command, since regardless of who was the pilot manipulating the controls, the pilot in command is by regulation the highest authority for the operation of an aircraft, is responsible for it and, as the operator's representative, for the safety on board of its crew, passengers and cargo, whether on the ground or in the air. It is also worth mentioning that the pilot in command is responsible for judging decisions and monitoring the actions and behaviour of the less experienced pilot and, if necessary, correcting certain actions for the purpose of the proper conduct of the flight. Also, there was poor cockpit resource management (CRM), in the sense that although the flight was a tourist flight, in the front seats of N7381G there were two conscious pilots, one with a Commercial Pilot Licence and instrument rating and the other with a Private Pilot Licence and about to complete his instrument flight lessons, fully capable and with the necessary training to perform the planned flight on the day of the accident, however, it is evident that there was inadequate coordination and communication between the two pilots, especially when entering the clouds.
5. This chain of events resulted in a controlled flight into terrain (CFIT), in which, when the crew realised the error and regained situational awareness, they no longer had enough time to adequately analyse the options, This led the pilot in command to make a decision that, according to his judgement, training and experience, seemed to him to be the best and least damaging to the ground and on board N7381G, given the conditions at that precise moment.
Contributing factors
1. Complacency on the part of the dispatcher of the operator of N7381G, as on the day of the accident he allowed the flight to depart without GPS equipment, when cloudy conditions had already been reported on the planned route.
2. Poor or no maintenance of the aircraft's instruments. This included inspections of the altimeter system, transponder inspections and ELT inspections, all mandatory inspections required periodically in accordance with CFR Part 43 of the United States and RAC 43 of El Salvador, which were overdue on the day of the accident.
3. The compass correction booklet installed in the cockpit of the N7381G had a format that induced an incorrect interpretation of the compass. Both the pilot in command on the day of the accident and other pilots who used to fly N7381G stated that the correction booklet states that to head north (N) one should actually fly a heading of 030°, which they interpret as a compass deviation of 30° to the right. When looking at the correction chart (which was installed in the aircraft cabin on the day of the accident), due to its format, one tends to think at first that the compass shows the aforementioned deviation, however, after carefully analysing the chart, it is verified that this is an interpretation error and that in reality the deviation of the compass is between 4° and 7°.
Accident investigation:
 |
|
Sources:
https://www.elsalvador.com/noticias/nacional/accidente-de-avioneta-en-zona-del-boqueron-deja-cuatro-lesionados/651017/2019/
https://www.tn23.tv/2019/10/19/el-salvador-avioneta-se-precipito-a-tierra-dejando-dos-fallecidos/
https://www.elsalvador.com/noticias/nacional/seis-accidentes-de-avionetas-registrados-en-el-salvador-en-la-ultima-decada/651165/2019/
https://www.aac.gob.sv/?wpdmpro=declaracion-provisional&wpdmdl=5678
https://www.jetphotos.com/photo/9214115 (photo)
Images:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 20-Oct-2019 06:08 | gerard57 | Added |
| 20-Oct-2019 07:38 | Arno Witte | Updated [Aircraft type, Narrative] |
| 20-Oct-2019 07:46 | harro | Updated [Time, Cn, Location, Source, Photo] |
| 20-Oct-2019 07:57 | RobertMB | Updated [Time, Operator, Location, Source, Narrative] |
| 03-Feb-2021 10:12 | harro | Updated [Time, Operator, Departure airport, Source, Category] |
| 21-Aug-2021 09:35 | harro | Updated [Destination airport, Narrative, Accident report] |
| 21-Aug-2021 09:35 | harro | Updated [Accident report] |
Corrections or additions? ... Edit this accident description
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