Wednesday, 8th of February, 1989
– Portugal
Independent Air Flight 1851, an international charter flight from Orio al Serio Airport, Bergamo, Italy, to Punta Cana, Dominican Republic, with a stopover at Santa Maria Airport, Santa Maria, Azores, operated with a Boeing 707-331B, registration N7231T, crashed into the Pico Alto while on approach about 7 km (4.4 mls) east of Santa Maria-Vila do Porto Airport, Azores, Portugal.
The aircraft was completely destroyed. The seven crew members and 137 passengers perished. (144 fatalities)
The crash of Flight 1851 is the deadliest aviation accident on Portuguese soil. It is also the fourth worst accident involving the Boeing 707 and the only fatal accident in Independent Air history.
– Details:
Independent Air flight IDN1851, a Boeing 707, departed Bergamo, Italy (BGY) at 10:04 UTC for a flight to Punta Cana, Dominican Republic (PUJ) via Santa Maria, Azores (SMA).
At 13:56:47 Santa Maria Tower cleared the flight to descend to 3000 feet for a runway 19 ILS approach: “Independent Air one eight five one roger reclear to three thousand feet on QNH one zero two seven and runway will be one niner.” In that transmission, the trainee controller had transmitted an incorrect QNH that was 9 hPa too high. The actual QNH was 1018.7 hPa.
After a brief pause the message resumed at 13:56:59: “expect ILS approach runway one niner report reaching three thousand.” This transmission was not recorded on the voice recorder of Flight 1851, probably because the first officer keyed his mike and read back: “We’re recleared to 2,000 feet and ah … .” The first officer paused from 13:57:02 to 13:57:04, then unkeyed the mike momentarily. This transmission was not recorded on the ATS tapes.
In the cockpit, the first officer questioned aloud the QNH value, but the captain agreed that the first officer had correctly understood the controller.
After being cleared for the ILS approach the crew failed to accomplish an approach briefing, which would have included a review of the approach plate and minimum safe altitude. If the approach plate had been properly studied, they would have noticed that the minimum safe altitude was 3,000 feet and not 2,000 feet, as it had been understood, and they would have noticed the existence and elevation of Pico Alto.
At 14:06, the flight was 7.5 nm from the point of impact, and beginning to level at 2,000 feet (610 meters) in light turbulence at 250 KIAS. At 14:07, the flight was over Santa Barbara and entering clouds at approximately 700 feet (213 meters) AGL in heavy turbulence at 223 KIAS. At 14:07:52, the captain said, “Can’t keep this SOB thing straight up and down”. At approximately 14:08, the radio altimeter began to whine, followed by the GPWS alarm as the aircraft began to climb because of turbulence, but there was no reaction on the part of the flight crew. At 14:08:12, the aircraft was level when it impacted a mountain ridge of Pico Alto. It collided with a rock wall on the side of a road at the mountain top at an altitude of approximately 1,795 feet (547 meters) AMSL.
– Cause:
“PROBABLE CAUSE: “The Board of Inquiry understands that the accident was due to the non-observance by the crew of established operating procedures, which led to the deliberate descent of the aircraft to 2000ft in violation the minimum sector altitude of 3000ft, published in the appropriate aeronautical charts and cleared by the Santa Maria Aerodrome Control Tower.
Other factors:
1) Transmission by the Santa Maria Aerodrome Control Tower of a QNH value 9 hPa higher than the actual value, which put the aircraft at an actual altitude 240ft below that indicated on board.;
2) Deficient communications technique on the part of the co-pilot, who started reading back the Tower’s clearance to descend to 3000ft before the Tower completed its transmission, causing a communications overlap.;
3) Violation by the Aerodrome Control Tower of established procedures by not requiring a complete read back of the descent clearance.;
4) Non-adherence by the crew to the operating procedures published in the appropriate company manuals, namely with respect to cockpit discipline, approach briefing , repeating aloud descent clearances, and informal conversations in the cockpit below 10000ft.;
5) General crew apathy in dealing with the mistakes they made relating tot the minimum sector altitude, which was known by at least one of the crew members, and to the ground proximity alarms.;
6) Non-adherence to standard phraseology both by the crew and by Air Traffic Control in some of the air-ground communications.;
7) Limited experience of the crew, especially the co-pilot, in international flights.;
8] Deficient crew training, namely concerning the GPWS as it did not include emergency manoeuvres to avoid collision into terrain.;
9) Use of a route which was not authorized in the AIP Portugal.;
10) The operational flight plan, whose final destination was not the SMA beacon, was not developed in accordance with the AIP Portugal.”
– Transcript of the Cockpit Voice Recorder (CVR) :
13.43:57 RDO-3 Santa maria Independent Air one eight five one.
13.44:07 APP One eight five one Santa Maria go ahead.
13.44:11 RDO-3 Good morning sir I would like to request your current met report Santa Maria.
13.44:20 APP One eight five one wind two six zero … Fourteen ah fourteen knots maximum two four knots visibility more than ten kilometers one octa at one two zero zero feet six octa at three thousand feet ah temperature one seven QNH one zero one niner.
13.44:44 RDO-3 One eight five one ah say active runway please.
13.44:48 APP Say again.
13.44:50 RDO-3 OK thanks.
13.44:50 APP Roger.
13.44:50 CAM-? It’s raining to the south.
CAM-? How do like there …
CAM-? Lorie it eyes good.
CAM-? … OK very good.
CAM-? Real strong cross wind gotta came in something like that.
13.45:58 CAM-? — Three zero zero – rain.
13.46:13 CAM-? Nobody ever told me anything – like this.
13.46:26 [Santa Maria VOR morse code]
13.48:16 RDO-2 Santa Maria Control Independent Air one eight five one like to descend
13.48:23 RCC Independent Air one eight five one clear to descend to flight level four zero.
13.48:30 RDO-2 Cleared to flight level four zero Independent Air one eight five one.
CAM-? — (woman’s voice)
CAM-? You are #
13.54:09 CAM-? Don’t laugh #
CAM-? About twelve #
CAM-? [Laughter]
13.56:16 CAM-? Thank you #
13.56:22 CAM-? Close that door it’s a jungle out here.
CAM-? Don’t set up.
CAM-? First time in the Azores # Always have these clouds hanging over like this #
CAM-? Ya #
13.55:49 RCC Independent Air one eight five one what’s your passing level.
13.55:53 RDO-2 Passing flight level two two zero.
13.55:57 RCC Roger report Echo.
13.56:00 RDO-2 Report ECHO Independent one eight five.
13.56:15 RDO-2 Independent one eight five zero … one eight five one ECHO at present time.
13.56:23 RCC Roger Independent one eight five one contact Santa Maria tower on one on eight decimal one.
13.56:28 RDO-2 One one eight decimal one good day.
13.56:35 RDO-2 Good afternoon Santa Maria tower.
RDO-2 Independent Air one eight five one passing flight level two zero zero for level four zero.
13.56:47 TWR Independent Air one eight five one roger you’re cleared to three thousand feet on QNH one zero two seven and ah runway will be one niner.
13.56:59 RDO-2 We’re cleared to two thousand feet and a … one zero two seven.
13.57:05 CAM-1 Make it three.
CAM-? —
13.57:12 CAM-2 Is that what he said ten twenty seven on the millibars.
CAM-1 Yeap.
CAM-3 Seat … belt sign.
CAM-2 It’s on.
CAM-3 Window heat.
CAM-2 Low.
CAM-3 Anti-ice.
CAM-2 Off.
CAM-3 Logo lights.
CAM-2 Off.
CAM-3 Emergency brake pressure.
CAM-3 Brake pressure.
CAM-2 (OK)
13.57:37 CAM-3 Altimeters.
CAM-1 Set and crosscheck.
CAM-2 Set and crosscheck.
13.57:43 CAM-3 Landing data EPR and airspeed bugs.
CAM-1 One twenty five.
CAM-2 One twenty five on the right.
CAM-1 Eighty-two seventy-nine.
CAM-2 Set and crosschecked.
CAM-3 Seatbelt and shoulder harness.
CAM-1 On the left.
CAM-2 Secured.
CAM-3 ()
13.58:09 CAM-3 We’re havin’ fun now.
CAM-1 Hey hey.
CAM-2 We’re havin’ fun now aren’t we.
CAM-? Yeah.
13.58:16 CAM-3 Almost as much fun —
CAM-? I haven’t heard heard that one.
CAM-? I hadn’t either.
CAM-? Where’d you hear that … where’d you come with that.
CAM-? Yeah.
CAM-? —
CAM-? [Laughter]
13.58:49 CAM-1 #
13.59:02 CAM-2 Why is this DME a hundred and ninety eight miles we are closer than that.
CAM-2 ()
13.59:08 CAM-2 I don’t think they got a … I don’t think they got a DME at Santa Maria.
13.59:15 CAM-2 We got to be close to it.
13.59:18 CAM-1 Seventy miles.
13.59:32 CAM-2 Out of ten.
CAM-? [Sound]
14.02:14 CAM-2 Rudder Leon.
CAM-2 Leon.
CAM-1 (Whenever you’re ready) maestro.
CAM-? Maestro … ah ah.
14.02:28 CAM-1 () Ain’t too hot out here.
14.02:31 CAM-? Yeah we’ll get down below … depends on what level those are.
CAM-? [Trim sound]
CAM-? [Whistling]
14.03:18 CAM-2 OK I’m gonna go ahead and put the ILS on mine Leon.
CAM-1 OK.
CAM-2 One ten three.
14.03:55 CAM-2 Ah after two thousand yeah we’ll get below these clouds.
14.04:19 CAM-1 In case we don’t … one eight seven is the outbound.
CAM-2 Yeah.
CAM-? [laughter]
CAM-? ()
14.05:41 CAM-2 Ah tousand to go.
14.05:43 CAM-? (One to go)
14.05:51 CAM-? [Sound of engine igniters]
14.06:01 CAM-3 There is the island.
CAM-2 Where is the airport.
CAM-? On the other side of the island.
14.06:15 CAM-? [Sound of altitude alert – 500ft above selected altitude]
14.06:17 CAM-2 (Four hundred) to go
CAM-2 (Don’t know if we are going to get visual or not here)
CAM-? (Gonna get rained on I know what)
14.06:46 CAM-3 Yeah.
CAM-1 [Sound of landing gear warning horn?]
CAM-? (There is no place like Santa Maria it looks nice)
CAM-? Is it.
CAM-1 (To have a beer)
14.06:57 CAM-1 We are level at two.
CAM-2 Yeah.
CAM-1 — To the left.
CAM-1 (At eight DME)
CAM-? () Cliffs.
CAM-? Yeah.
14.07:34 CAM-2 Starting to pass throughout layers here.
14.07:52 CAM-1 Can’t keep this SOB thing straight up and down.
14.07:57 CAM-2 () Help you.
CAM-1 No.
CAM-? ()
CAM-? ()
CAM-? [Sound of radio altimeter]
14.08:05 GPWS Whoop whoop pull up Whoop whoop pull up Whoop whoop pull up Whoop whoop pull up
14.08:12 [Sound of impact]
