reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2012 Citation fog CFIT Santiago Spain

Brief account : 

The Citation was being  positioned to base following a medical team transfer.  The investigation was hampered by the lack of either CVR or FDR information. 

With a number of background technical and organisational deficiencies, the crew made an unstabilized ILS approach and did not follow the Santiago Airport glide slope, using distance references to the VOR instead of the runway.  There was fog in and around the airport which could have affected suddenly the crew's ability to see the ground.

Both pilots were killed and the aircraft was destroyed when it hit the ground about a mile short of the runway.  

Crew-related factors : 

The Captain as PF was relatively experienced, the F/O significantly less so. The F/O's instruments had some defects.  The crew had been called from standby and were probably fatigued; they were also under pressure to land having inadequate fuel to divert.  There is anecdotal evidence that they may have also broken minima to land when delivering the medical team on the outbound leg. 

The absence of voice and data recordings makes it difficult to judge cockpit activity, but there is ample evidence that the actual visibility in the final approach area could have been much worse than the "4000m mist, few at 600ft"  that reports indicated. The report says the approach was probably flown manually as a sort of non-precision approach rather than using the ILS glideslope.

Aircraft defects might have it hard for a PicMA to have been flown, but if so 

1) it would have at least provided the pilot with more opportunity to assess the visual cues,

2) the F/O would probably have used the ILS glideslope for guidance.  

Type: 
Cessna Citation
Where: 
Santiago Spain
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
Unknown
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
2012
Time: 
Night
Deterioration: 
Yes
Vert Guidance: 
Available, unused
Both Head Up: 
No
LoC: 
No
Operator: 
Airnor
Fully prepared: 
No
Actual Weather: 
Fog
Autopilot : 
Unknown
CCAG: 
Normal