Accident Details
The aircraft, carrying 31 tons of telecommunications equipment for a Portuguese telephone company, departed Macau, China, bound for Baucau, Timor-Leste. On board were two passengers and four crew members. During the landing approach, the aircraft impacted terrain near Caicido village, approximately 1 nautical mile (1.87 km) northwest of Cakung Airport, Baucau. The pilot in command was the handling pilot during the descent and approach. The aircraft was destroyed by impact forces and a severe post-impact fire. All six occupants — the flight crew (pilot in command, copilot, flight navigator, and flight engineer) and two loadmasters — suffered fatal injuries.
Weather Conditions
At the time of the accident, low cloud was present near the aerodrome. Witnesses estimated the cloud base at about 1,000 feet (305 m) above ground level, with visibility approximately 1,500 meters (0.8 nautical miles). Before departure from Macau, the flight crew received notices to airmen (NOTAMs) and weather forecast information for the planned flight. However, no terminal aerodrome forecast (TAF) or aviation routine weather report (METAR) was provided for Baucau, as those forecasts were not produced for that airport.
Investigation Findings
The official investigation identified several findings. Air traffic services were not available at Baucau at the time, and no procedure existed to provide flight crews of non-United Nations operations with an altimeter subscale setting for Baucau. Organizational findings indicated that neither the Lao-based company nor the Cambodian-based company sought consent for a proposed sublease, dated 18 November 2002, and accordingly the inferred sublease had not been finalized. The Cambodian-based company was not the operator of the aircraft for the occurrence flight. The Lao People's Democratic Republic was the State of Registry and State of the Operator. The Lao Department of Civil Aviation was responsible for continued surveillance of the operator to ensure required standards were maintained. The operator provided flight crews with inflight controlled flight into terrain (CFIT) avoidance procedures in its operations manual.
The planned flight from Macau to Baucau was exposed to moderate risk of a CFIT event, based on historical CFIT data and the Transport Canada simple method of risk analysis. Destination risk factors, type of operation, area of operation, weather conditions, and flight crew non-compliance with published procedures increased the CFIT risk exposure to an above-average level. The consequences of the accident were catastrophic, resulting in loss of human life and damage to property and the environment. Those consequences resulted from the flight crew's disregard of established procedures, which bypassed safety criteria and increased CFIT risk exposure to an extreme level during the latter stages of the flight.
Significant factors included: the flight crew did not comply with the published non-precision instrument approach and/or missed approach procedures at Baucau during flight in instrument meteorological conditions; they conducted user-defined non-precision instrument approaches to runway 14; the pilot in command permitted the aircraft to descend below the minimum descent altitude (MDA) published on both the Jeppesen and CAD runway 14 instrument approach charts; and the flight crew did not recognize the increased likelihood and risk of CFIT, nor treat that risk in a timely manner.