What happened
On January 14, 2002, an EMB-120-ER EC-GTJ, operated by Ibertrans, was performing a scheduled cargo flight from Madrid-Barajas to Bilbao. The aircraft was carrying 2,873 kg of cargo and was occupied by two crew members and one maintenance technician acting as a passenger.
At approximately 07:23 local time, the aircraft was cleared by Bilbao Approach for an ILS approach to runway 30. Shortly after being transferred to Bilbao Tower, the aircraft failed to establish communication. The aircraft impacted the terrain at Monte Santa Marina, near Zaldilibar, at an elevation of 675 meters. The impact occurred while the aircraft was in a climbing attitude and in a flight path aligned with the approach axis, approximately 18 nautical miles from the runway threshold. The crash resulted in 3 fatalities.
The investigation
The CIAIAC investigation examined the flight path, the aircraft's performance, and the crew's actions. Investigators analyzed the flight data from the DFDR and cockpit voice recordings from the CVR. The investigation focused on the aircraft's attitude, the performance of the autopilot, and the crew's adherence to standard operating procedures (SOPs). The investigation also reviewed the operator's training programs, specifically regarding Crew Resource Management (CRM), and evaluated the technical manuals provided by both the operator and the aircraft manufacturer regarding the autopilot system.
Findings
- The primary cause of the accident was the crew's failure to maintain adequate separation from the terrain during the approach to Bilbao.
- The crew's attention was fixated on the disconnection of the autopilot, which led to a loss of situational awareness.
- The crew failed to follow established standard operating procedures once difficulties with the flight controls arose.
- The crew experienced a breakdown in task management and failed to perform cross-checks, as they were both focused on the same task.
- There was a lack of prospective memory, evidenced by the crew initiating altitude settings in the altitude warning system but failing to complete the necessary procedures.
- At the time of the accident, the pilots had not received formal Crew Resource Management (CRM) training.
- Discrepancies were found in the documentation: the operator's standardization manual omitted specific autopilot limitations and procedures, and the aircraft's flight manual lacked certain pitch trim system check procedures in its normal descent section.