Fatal Mountain Strike During Night Departure from Lajes Airport (HK-163)

Incident Overview and Flight Details A crew was operating a transatlantic flight from Hamburg to Bogotá, with intermediate stops at Frankfurt, Paris, Madrid, Lisbon, Ponta Delgada, and Hamilton. During a night approach to Ponta Delgada, the crew was informed of fog at the destination. Because visibility was below minima, the captain decided to divert to Lajes. After an uneventful refueling stop, the crew took off from Lajes Airport at 0237 local time, bound for Hamilton, Bermuda. ## Crash Sequence Three minutes after departing runway 34, while climbing, the four-engine aircraft struck the slope of a mountain and burst into flames approximately 9 km southwest of the airport. The aircraft disintegrated on impact, and all 30 occupants were killed. ## Official Probable Cause The official investigation determined that the probable initial cause was the pilot's failure to carry out the normal climb-out procedure following takeoff from runway 34. Instead of turning right, the pilot made a turn to the left, causing the aircraft to fly into the mountains rather than turning out to sea. The investigation disregarded the possibility that the aircraft was forced to make a left turn, as examination of the wreckage indicated no mechanical failure occurred. ## Procedural and Terrain Context The required procedure had been explained to the crew during the briefing and in instructions given by the tower. The chart of Lajes in the route manual supplied to the crew clearly showed that all turns must be made towards the Northeast. The crew members who attended the briefing office apparently considered the right turn following takeoff a secondary matter, focusing instead on proceeding directly to Ponto Sul to avoid collision with the mountains, the highest point of which reached 7,615 feet. The presumed heading flown by the aircraft before the crash indicated that the pilot intended to proceed to Ponto Sul. However, the pilot appears not to have realized that doing so required turning eastward towards the sea, not westward over the land. According to the company, this was the captain's first landing at Lajes. At Santa Maria, where the captain had landed several times, the takeoff procedure for flights towards the Northwest in the direction of Bermuda also involved a turn towards the sea, but that turn was made to the left because the airport is located on the extreme west of the island. The point known as Ponto Sul is shown on the reproduced 1:1,000,000 chart. Examination of this chart explains the reason for the standard procedure in the Azores control area, whereby aircraft are required to fly over this point before proceeding towards Bermuda, in order to avoid the high ground on Terceira, S. Jorge, Pico, and Faial Islands. Since Lajes Airport is located in the extreme Northeast of the island of Terceira, the safety requirement to turn east and out to sea to avoid the mountains on the island is considered obvious in view of the nature of the terrain.