The January 2003 fatal crash of an Ilyushin Il-76TD at Bacau, East Timor happened because the aircraft made an unstabilised non-precision descent that continued below the published minimum approach height, says the Australian Transport Safety Bureau (ATSB) final report on the accident, writes Emma Kelly.
The ATSB, which investigated the crash on behalf of the East Timor government, says poor crew co-ordination and flight planning also contributed.
The aircraft crashed in bad weather 2km (1nm) north-west of Cakung airport, Bacau after hitting terrain during a second landing attempt on a flight from Macau, China. All six crew were killed in the controlled flight into terrain (CFIT) accident. Air traffic services (ATS) at Bacau were not operating at the time.
During the approach, the flightcrew's course of action made the CFIT risk very high, says the ATSB, adding that they were unaware of the danger of impact until about 2.5s before.
The ATSB says the flightcrew did not comply with published procedures for the approach at the unmonitored airport. They did not have accurate aerodrome charts, crew resource management was poor, and they failed to obtain updated weather information, to monitor the Timor local common frequencies, and to broadcast their intentions.
According to the report, the crew used selected data from their instrument approach charts to carry out a user-defined non-precision approach making use of their GPS satellite navigation system. During the final approach, the rate of descent was high and unstabilised, and the Il-76TD descended through the published minimum descent height of 531ft (162m). Such an approach meant the risk of CFIT was "unacceptably high", says the ATSB, which issued safety recommendations in response to the crash last year.