What happened
During a positioning flight, the crew attempted an ILS approach to runway 18. While the aircraft was approximately 5 nautical miles to the left of the localizer, the captain reported that the signal was not being received. Following this, the crew initiated a missed approach but failed to adhere to the established missed approach procedures. The captain subsequently obtained clearance for a VOR approach to runway 25.
As the aircraft proceeded toward the VOR, the captain provided a partial briefing and began describing the remaining phases of the approach as they unfolded. During the outbound leg of the procedure turn, the captain instructed the first officer to maintain 4,700 feet, despite the outbound course requiring a minimum altitude of 4,300 feet. The captain then issued an incorrect heading, directing the aircraft in the wrong direction, which resulted in an outbound duration of approximately two minutes.
During the outbound portion of the course reversal, the captain ordered a descent to 2,900 feet, violating the minimum altitude requirements. As the aircraft transitioned to the inbound leg, the altitude was further reduced to 3,000 feet. Upon reaching the outer marker, the captain suggested the aircraft could descend to 2,300 feet. Despite the first officer noting that VOR indications were unstable, the first officer proceeded with the descent to 2,300 feet. Three seconds later, the aircraft struck trees and terrain. The wreckage was found at the 2,300-foot level on rising mountains, approximately 12.5 nautical miles from the VOR, well before the altitude was authorized for descent.
Findings
- The crew failed to follow the prescribed missed approach procedures.
- The captain provided incorrect navigational headings during the course reversal.
- The crew descended below the required minimum altitude during the outbound and inbound phases of the procedure turn.
- There was no evidence of mechanical failure prior to the impact.
- The crew did not utilize available DME information during the approach.