Flight Sequence
The National Transplant Organization (ONT) informed Santiago Airport (LEST) at 20:40 of a planned hospital flight. The aircraft, EC-IBA, was refueled at Santiago with 1062 liters of fuel. At 21:46, the crew contacted Santiago tower for startup clearance and weather information for Asturias. Cleared for takeoff at 21:54, the aircraft landed at Asturias (LEAS) at 22:27. The hospital flight service commenced at 22:15. At 22:30, the Rescue and Fire Fighting Service (RFFS) escorted the ambulance to the aircraft. The aircraft took off for Porto at 22:44. Madrid control transferred the aircraft to Santiago approach at 22:52 at flight level 200, cleared direct to Porto. The aircraft landed at Porto at 23:40.
While waiting for the medical team, the crew remained at Porto's facilities. Personnel noted crew comments about bad weather, including fog on the arrival route. At 01:34 and 02:01, the crew received flight plan information, ARO-LPPR office data, and updated weather. The aircraft was refueled at Porto with 1000 liters of fuel and took off at 02:34. At 02:44, the aircraft contacted Santiago approach to report position. Four minutes later, the crew directly contacted Santiago tower for weather conditions at the field. The aircraft landed again at Asturias at 03:28. At 03:26, RFFS was activated again to escort the ambulance. The service was deactivated at 04:00. The crew requested updated weather from the tower, receiving the 03:00 METAR. According to the filed flight plan, estimated off-block time from Asturias was 03:45, with an estimated flight time of 40 minutes to Santiago. The alternate destination was Vitoria (LEVT).
Communications and Final Approach
The aircraft took off from Asturias at 03:38. At 03:56, the crew contacted Santiago approach control, which provided the latest METAR from 03:30: runway 17 in use, calm winds, visibility 4000 meters with mist, few clouds at 600 feet, temperature and dew point 13°C, QNH 1019. The aircraft was cleared for an ILS approach to runway 17. At 04:15, the crew contacted the tower controller, who reported calm winds and cleared them to land on runway 17.
Search and Rescue
At 04:18, the COSPAS-SARSAT system detected activation of an ELT, estimating its position near LEST airport. At 04:38, the tower controller informed airport operations of a SAR call about an active beacon and requested a marshaller check the aircraft's normal parking spot. At 04:44, the marshaller confirmed the aircraft was not in its hangar, activating the emergency procedure and notifying search parties. At 05:10, the control tower called the airport to initiate the preliminary phase (Phase I) before activating Low Visibility Procedures (LVP). At 05:15, RFFS reported the aircraft found near the VOR. At 05:30, LVP Phase II was initiated. At 07:51, LVP was terminated. The last flight to arrive at Santiago before the accident landed at 23:33; the next after the accident landed at 05:25.
Probable Cause
The official investigation could not determine the ultimate cause of the accident. The most likely scenario is that the crew conducted a non-standard precision approach manually, based primarily on distances. The ILS frequency set incorrectly in the first officer’s equipment and the faulty position indicated on the DME switch resulted in the distance shown on the captain’s HSI corresponding to the VOR rather than the runway threshold. The crew shortened the approach maneuver and proceeded to a point where the aircraft should have been established on the localizer, increasing workload. The crew probably lost visual contact with the ground when the aircraft entered a fog bank near the airport and did not realize they were approaching the VOR instead of the runway. Contributing factors included: lack of operational procedures for an aircraft authorized for single-pilot operation but crewed by two members; the overall condition of the aircraft and instruments and crew mistrust of onboard instruments; fatigue from working during a period normally reserved for sleep after an unplanned duty period; and concern about fuel diversion to alternate combined with complacency upon reaching the destination.