Microsoft word - informe de accidente - ingles.doc

This report is a technical document which reveals the opinion of the JUNTA DE INVESTIGACIONES DE ACCIDENTES DE AVIACIÓN CIVIL (Air Accident Investigation Commission) regarding the events which surrounded the accident that is being investigated, As stipulated in Exhibit 13 of the CONVENIO SOBRE AVIACIÓN CIVIL INTERNACIONAL (INTERNATIONAL CIVIL AVIATION AGREEMENT) (Chicago /44) confirmed by Law 13.891 and by Section 185 of the AERONAUTICAL CODE (Law 17.285), this investigation obeys to strictly technical matters and does not include any conclusions, presumptions of wrongful acts, or administrative, civil or criminal responsibilities over the The investigation has been carried out without applying procedures for evidence of judicial type, but with the main objective of preventing future accidents. The results of this investigation are not contingent upon or prejudge other results from administrative or judicial investigations that could be initiated subject to in force laws in THE ACCIDENT TOOK PLACE: at 38 kilometers SSE of the locality of Pareditas, San Carlos AIRSHIP: Aircraft TRADEMARK: Cessna 340 TYPE: C-340 LICENSE: N5YOOM Pilot License for Airline Transportation Airplane COPILOT: Pilot License for Airline Transportation Airplane OWNER: Ward County Irrigation District N0 1 (USA) Al hours are shown in Universal Time Coordinate (UTC) which corresponds to 3 for the time zone at the place of the accident. On February 7, 2005 at 04:30 hours at the San Rafael aerodrome a meeting, previous to a flight for “ Hail Suppression” (HS), was carried out with the participation of the Chief of Operations and the outgoing and incoming crews. In this meeting issues about the meteorological conditions that could arise in the area of work and the general conditions of the aircraft License N5790M were addressed. The pilot took off in the N5790M aircraft at 05:04 hours from the mentioned aerodrome using the indicative TRUENO for the communication with the Air Traffic Services. 1.1.4 He immediately flew to the HS area, “District of Tunuyán”, to perform the “airborne seeding” guided by the Radar Operator from the Tunuyán Operations Center (OC). The pilot was responsible for flying the aircraft and for the communication with the San Rafael Tower in 118,1 MHz frequency and with the OC in an internal frequency; while the copilot was responsible for operating the HS console y safety measures. At 05:07 hours the pilot contacted the OC for the first time, informing that he was flying, climbing by IMC Instrument Meteorological Conditions and heading North. . The OC operator acknowledged receipt and informed the pilot about the location of the storm cel s, which he was observing in the radar´s screen, indicating the course and distance to them in order to perform the airborne seeding. According to the communications report and the telemetry data obtained from the radar´s file, connections with the OC were normal. In the first part of the flight the aircraft was flying at an altitude of 8000 ft. Later, the pilot in a communication with the OC stated. “Oh. yes, the thing is Marcelo that here we are at seven thousand nine hundred feet and the clouds are here at our level, I am going to have to keep descending…” . Records indicate that as of that moment he started descending due to meteorological conditions and to be seen from the ground and in VMC. In the area where the pilot was flying there were low clouds roofs and strong Descent was below the minimum established for the grid in the visual maps (5800 ft) and what the Operations Manual specifies. The minimum altitude recorded at the time The OC Operator, who knows the area, alerted the pilot over the obstacles that he could face in the area in which he was flying. Even though the pilot acknowledged receipt of the information, he kept descending within the clouds and as he observed oscil ations in the radio altimeter, he leveled the aircraft to 6000 feet by altimeter and stated doubts about the correct operation of the Afterwards, the pilot resumed the airborne seeding, but at altitudes under 5500 At 06:33 hours, while flying between 5300 / 5500 feet, inside and outside the clouds, the OC Operator assigned the pilot an echo in the area to perform the seeding. Three minutes later, with updrafts (200/300 feet/meter) the crew started the At 06:41:28 hours the radar operator instructed the pilot to return through the right, with 270º course, to the area he had flown earlier, crashing at 06:41:32". At 06:44:18 the operator tries to get in touch with the aircraft and repeats the As he saw his efforts were in vain, and facing an emergency situation the Search and Rescue (S&R) systems were alerted. The aircraft was found at 13:45 hours by the rescue patrols at about 38 kilometers SSE of the locality of Pareditas, total y destroyed and burnt. The accident took place flying by instrument meteorological conditions (IMC) The aircraft was destroyed due to the impact against the ground. The pilot in charge was 41 years old, held Private Pilot, Commercial, First Class Commercial and Transportation Airline Airplane Licenses. He was authorized to fly at night and by instruments in single-engine and multi- His Psycho-physiological Fitness Certificate Class 1 expired on October 31, He did not record any accidents or infractions. Accumulated experience in flying hours was:: In the type of aircraft in which the accident occurred: 43.7 From the data obtained from the Flight Book, it was determined that the pilot had not performed flying activities during nine months, from April 1 to December 23, 2004, date on which he was instructed on the Cessna 340 aircraft by a Flight Instructor, according to NOCIA Normas para la Obtención de Certificados de Idoneidad Aeronáutica (Standards to obtain The copilot was 43 years old and held Private Pilot, Commercial, First Class Commercial, Flight Instructor and Transportation Airline Airplane Licenses. He was authorized to fly at night and by instruments in single-engine and multi- engine aircrafts up to 5700 kilograms and in ARAVA aircrafts and copilot F-27 aircrafts. His Psycho-physiological Fitness Certificate Class 1 was effective until October 30th and did not recorded any accidents or infractions. 1 .5.2.4 The Flight Book was not found. The only record from which hours of flight were obtained was from the information submitted by the HS Base at San Rafael. Accumulated experience in flying hours was: In the type of aircraft in which the accident occurred: 18.1 From the records of the pilots activities, it was determined that since December 1, 2004 until the day of the accident the total HS flight activity was 14 hours, of which 05.3 hours were flown with the pilot in the accident. The aircraft was a Cessna, model 340, Series Number 340-0044, manufactured by Cessna Aircraft Company, license N5790M, owned by Ward County Irrigation District N0 1 Total y manufactured of metal ic material, semi-monocoque type, low wing, tricycle landing gear with wheels and retractile system. It was equipped for hail suppression and The original Airworthiness Certificate was for Normal Category and was issued On May 1, 2001 it was certified for Restricted Category. Both certificates were issued by the FAA, USA and revalidated by the Dirección Nacional de Aeronavegabilidad de Argentina (DNA) (National Agency of Airworthiness of Argentina) on December 22, 2004 and due on April 15, 2005, date on which the HS 2004/05 Maintenance was in charge of a technical representative with USA License, while the technical support, special tools and documentation were provided by a shop identified by The cockpit had 3984 hours of TG on February 7, 2005 and an ongoing type It was equipped with two Continental 310 hp counterrotation engines; the one located in position N0 1 was model TSIO 520 KCN, Series Number L217592, 3970 hours of TG and 1202 hours of DURG and the one located in position N0 2 was model LTSIO 520 KCN, Series Number 504139, 3141 hours of TG and 367 hours of DURG. The aircraft was equipped with two Hartzel metal ic propel ers, three-blade variable pitch type. Type of inspections: scheduled. Were model HCC34F2UF and since they were counterrotative were identified with the letter L for (LEFT) and R (RIGHT), Series Number EB 1652 (L), 2197 hours of TG and 1181 hours of DURG, Series Number EB 1654 (R), same TG and DURG, respectively. Calculated weights in kilograms at the time of the accident were: Difference: 325 less with respect to MTOW . The aircraft at the time of the accident weighted 325 kilograms less than MTOW and the Center of Gravity was within al owed limits. The aircraft was equipped with two devices located under each wing, close to the inner bend, for placing the cartridges used in HS. The copilot operated the console in the cabin, selecting the amount of cartridges The airplane had a Narco Avionics (TSO C91) ELT 10, Series Number 13569, which operated 1.7.1 The meteorological report on May 3, 2005 submitted by the National Meteorological Service, including the data obtained from the time records from the meteorological stations from the Mendoza and the San Rafael aerodromes, interpolated to the place and time of the accident, plus the satel ite images GOES 12, the ground synoptic maps at 06:00 and 09:00 UTC and the corresponding altitude charts of 700, 500, 300 and 250 hPa levels was: Wind: 180/08 kt; Visibility 10 kilometers; Important Phenomenons: visible lightning; Cloudiness: 3/8 SC 1100 m - 2/8 CB 1300 m; Temperature: 20.8º C; Dew Point:16.5º C; Pressure: 1007.4 hPa and Relative Humidity: 77% AEROMET Report from the San Rafael aerodrome 05:00 TUC 140/12 cts. 20 Km., visible lightning, 5 CU 1200 m. 2 CB 1500 m
06:00 UTO 14O/12 kts 20 km, visible lightning, 8 SC 1200 m. 2 CB 1500 m
According to FIR Mendoza, the important phenomenon was: warm and humid air mass and barometric depression at altitude create strong convective cloudiness with isolated storms, moderate turbulence in sector W of the FIR between FL 070/FL 230 and in convection The satel ite images obtained from the area flown by the aircraft between 05:10 and until 07:39 hours, one hour after the accident, showed that the meteorological conditions “Convective type clouds of varied vertical development with average temperatures of -50º C to FL 300 approximately and maximum temperature reaching -60º C to FL 350, approximately, which moved SE in the reference area, decreasing progressively in its vertical development. Such cloudiness is related to storm, turbulence, icing and probable hail The pilot had al the equipment necessary in the aircraft for the type of operation that he was performing, as stipulated by the Company Operations Manual and the Flying Regulations. The pilot maintained normal radio contact in VHF with the operator of San Rafael 1.9.2 Available facilities in the OC made it possible to count with the internal communications record from the person in control of the radar, recorded in a room recording system, as wel as the communications between the pilot and the OC. 1.9.3 This information al owed to evaluate and to acknowledge the situation which the pilot and the OC operator lived before the accident. Information about the place of the accident 1.10.1 The accident took place at about 3.8kilometers SW of the locality of Pareditas, District of San Carlos, Province of Mendoza. Geographical coordinates 34º 16’ 49” S - 068 58’ 1.10.2 The ground has a slight upgrade to the W and there are some low shrubs in the surface, and the elevation is 5250 feet above sea level. 1.11.1 The N5970M was not equipped with FDR or CVR, since this type of equipment is 1.11.2 The aircraft was equipped with an autonomous telemetry equipment with GPS linked to the OC of HS (TITAN) for fol owing in real time evolutions with respect to the convective cel s seen in the radar screen from the ground. 1.11.3 The data about the flight were obtained from the information transmitted by this 1.11.4 The information, which is similar to the one from a FDR (date, license, time, latitude 1 longitude, altitude and velocity) was used for the reconstruction of the flight. Information about the aircraft´s remains 1.12.1 The first indication was the contact of the right engine´s propel er with some bushes at about 48 meters prior to the first impact against the ground, 270º course.

1.12.2 During the displacement of the aircraft on the ground, parts of the aircraft were
1. At 29 meters from the first impact the tail plane, parts of left wing end careenages and the fork with the wheel from the nose landing gear were 2. From the previous place and 31 meters ahead, the fol owing was observed: signs of fire and parts of the fuselage in the bushes and pasture; the simultaneous detachment of the propel ers which remained at 12 rc on both 3. About 37 meters ahead, remains of the left wing and careenages were found. 4. After travel ing 36 more meters, the aircraft slightly turned right from the original course to 280º direction and in that course other parts became 5. About 31 meters ahead, parts of the right wing, engine careenages, remains of a back window and upholstery from the cabin were disseminated. . 6. From that position and 10 meters to the left, the main right gear including parts of the plane from the same side were found. The cartridges were found, they were stil instal ed, some of them had not been activated. 7. From the previous remains, 33 meters ahead and in a range of 25 meters, the main parts of the fuselage, the left wing and part of the main left gear retracted were found. About 3 meters to the left, the body of the pilot and the seat were found. The body of the copilot was next to the remains of the cabin. 8. Seventeen meters to the right of the cabin´s remains, the right engine was found, and to the left of it and 70 meters ahead, the left engine was found. 9. The mark left on the ground by the fire was concentrated from the last third part of the course of the aircraft and in the place where it final y came to a A forensic doctor examined the bodies of both members of the crew at the site of the accident, confirming that they had died at the time of the accident. The autopsy performed in the Judicial Morgue of San Rafael determined that the pilot died of severe politraumatism due to the type of injuries. There were no indications of contamination in the blood that could have negatively influenced in his psycho-physical The information about the copilot determined that the cause of death was similar to the pilot´s. In addition, the copilot had suffered the effects of the fire. At the time the wings and fuselage impacted against the ground, a large quantity of fuel was scattered through the whole area but the main fire started where the main aircraft body, fuselage and the right wing and cabin were found. 1.15.1 The crew died instantaneously as a consequence of the injures from the impact of the aircraft against the ground and to the decelerations they were exposed to. 1.15.2 The aircraft was found at 13:45 hours by the pilots from the Lama helicopters of the IV Brigada Aérea (IV Air Brigade) from Search and Rescue. They guided the ground patrol 1.15.3 During the investigation, it was not possible to confirm if the ELT in the aircraft 1.15.4 The Centro de Control de Misión de Argentina (ARMCC), the same day of the accident received a localization signal that did not correspond to the place of the accident. 1.15.5 The S&R system was immediately activated once the OC operator did not receive any answer from the pilot to the cal s on the radio. 1.16.1 From the investigations carried out on the technical aspects of the aircraft, it was determined that there were no failures in the cockpit, malfunction of the on board systems, engines or that an element came loose from the structure that could be related to the accident. 1.16.2 The identification plate of the aircraft was not found. The model and series number of the aircraft were found, marked, under the left horizontal stabilizer. 1.16.3 According to the statement of the copilot who was aboard the same aircraft in a previous flight, a possible failure in the radio altimeter was investigated. The telemetry information available in the OC and the visual maps used during the flight were compared in order to determine the course of the aircraft while in contact through The topography of the place which the aircraft flew over and the information from the OC records were compared with regard to the position and flying altitude and the information the pilot indicated to the Operator. Such comparison determined, with a high degree of certainty, that the information from the radio altimeter was correct The oscil ations were the result of the low altitude at which the aircraft was flying and of the orographic structures in the area, which were real y indicating the area´s relief. The technical reports of previous flights were verified to establish if any information about the performance of the radio altimeter had been reported. No reports had It was established that the OC Operator informed the pilot that he was flying over the hil El Divisadero and that there were other elevations of approximately 5000 feet, which were indicated on the screen. These elevations were the most relevant ones, such as the The meteorological radar of the OC, due to its technical features, includes information about the storm cel s but it does not indicate about the elevation of the obstacles in the ground; except for the aforementioned. The duty of the OC Operator was to vector the pilot to the convective cel s and not to offer flight support, nevertheless, this task was also performed to cooperate and obtain In regard to the matter, the Operations Manual of the company states that in such OC a pilot was to be present to support the operation. No shift for such purpose was According to statements from the investigation, it was found that the pilot had worked in previous HS campaigns performing the same task. Regarding previous campaigns, two changes took place that modified the operating conditions: The operations during night time and the limits and operation criteria were modified directing them to the West (area of higher elevations) with the intention to perform This change was not included in a change of the proceedures stipulated by the The avionic of the aircraft was not standardized, thus the pilot had to adapt to the Air traffic management was shared in different phases, between the ATC and the OC which vectored the aircraft to convective cel s. At first, the approximate location of the accident was determined using the telemetry capabilities of the radar, which was receiving the aircraft´s position every eight seconds, in coordinates, altitude and velocity. During the investigation, it was not possible to confirm if the ELT of the aircraft The ELT was inspected at the Tal er Servicios Electrónicos Aeronáuticos (Aeronautical Electronic Services Shop), establishing the correct operation of it, including the battery, the inertial element and the selector switch. Also, a test was carried out, activating the ELT manual y and the signal was captured by only one satel ite, thus the correct location of the equipment was not determined in It is worth mentioning that the cable from the equipment´s antenna was slashed. This might of been the cause for the COSPAS SARSAT not capturing the signal, and al owing Another aspect considered was the fact that for the ELT to be automatical y activated, it must face a deceleration of 5 G per 11 mil iseconds. In this case, the displacement of the aircraft on the ground in a lineal way, estimating an impact speed of 150 kts and the 255 meters it travel ed until it became to a stop, result in an average deceleration of approximately 1.18 G. Nevertheless, it is considered that the cause for the malfunction was the fact that the antenna was broken. The Aeronautical Maps of Argentina in a scale of 1:1000.000 CAA 7 effective in the country, with altitudes specified in meters, are the ones published by the Dirección de Tránsito Aéreo (Air Traffic Control), while the one used by the pilots for HS was the ONC R-23, with altitude in feet, edited by the Defense Mapping Agency (DMA USA). HS areas were marked in these maps, highlighted in yel ow and “plasticized”. Also, they had been marked and information about the HS had been included, thus the details indicated would not have been visible due to the amount of data added and light To these facts, the difficulty of reading a map during a night flight, where light is By comparing both maps, in safety sectors included in the HS area, the fol owing Also, data from the last 20 minutes of the flight for HS were obtained from the At 06:24 hours the aircraft was at an altitude of 5921 feet, according to the CAA- 7 map the minimum safety altitude in the area was 5774 feet while in the ONC R-23 map the According to the mentioned records, the aircraft was in the proximity of Cerro Tres Altitos of 4606 feet, in agreement with the indications of the radio altimeter . That is to say, the flight was taking place at an altitude of about 1164 feet over the ground, and the pilot did not understand the reasons for the oscil ations. The crew knew that the West limit of the area of work in a night flight was the radial 190 of the VOR Mendoza, and the place of the impact was over the 184º, thus such limit
The Hail Suppression Program (HS) was carried out as planned by the government of the Province of Mendoza, subject to the estipulations of the Provincial Decree N0 Such HS Program, according to the legal framework before mentioned, was fulfil ed subject to an Operational Agreement entered into by the government of the Province of Mendoza and the Fundación Argentina (Argentine Foundation) and another Col aboration Agreement entered into between the Government of Mendoza and the Argentine Air Force, through the HS Team of the IV Brigada Aérea (IV Air Brigade), created for such purposes. To carry out the HS Program, three US Cessna 340 aircrafts ((N98RM, N7622Q and N579OM) were used, which entered the country through a Rental Contract entered into between the Fundación Argentina – which carried out the HS activities – as the lessee and Fmpresa Nemiro SRL as the lesor of the mentioned aircrafts. The aircrafts assigned to the HS Program had their operations base at the Mendoza / El Plumeril o Airport or alternatively in the San Rafael / Santiago Germanó. Airport. 1.17.5 The HS areas of operation are delimited and divided into three Oasis: North, 1.17.6 For the HS operations within the Oasis, the fol owing Protected Areas were North Oasis: Gran Mendoza, San Martín and Rivadavia to La Paz. Central Oasis: Val e de Uco, Tunuyán, Tupungato and San Carlos. South Oasis: San Rafael, Bowen, General Alvear and Carmensa. HS flights show peculiarities not found in other type of operations since they have to be performed during daylight as wel as at night, and under critical meteorological conditions. Though, according to the Flight Handbook, the aircraft which took part in the accident could be flown by only one pilot, a co-pilot had been appointed due to the characteristics of the operation and in order to train new crew. The co-pilot was in charge of the operation of the cartridge ignition console used in cloud seeding. Different hail suppression systems are presently used world wide in order to reduce the negative effects of hail on different crop types. The techniques based on silver iodide seeding on the potential y hail-producing clouds belong to three different technologies: of These three systems coincide in their operation principles which state that in order to reduce hail damage silver iodide (Agl) must be seeded in the potential y dangerous nuclei (clouds which, according to their characteristics, could be considered potential hail In addition, they coincide in their scientific theory about the formation of clouds and in that to detect hail clouds they rely on meteorological radars. They differ only in the vehicle or vector used to transport the agent Agl from the ground to the cloud seeding zone; for Russian scientists the agent is conveyed by ground-air rockets, which seed the cloud with the agent while they fly pass the cloud; American scientists use flares and cartridges shot or launched as from aircraft towards the potential y dangerous clouds. (air- air seeding); and French scientists use ground generators which contain a solution of acetone mixed up with Agl. This solution, when heated, goes up as vapor and, it is expected to reach the drop formation zone of the clouds. These systems, with variations, are applied in more than 40 countries; here in Mendoza the American system is being used. Useful and efficient investigation techniques In order to investigate the causes of the accident, it was of fundamental importance to gather information from TITAN system telemetrical data which helped to reconstruct the entire flight and to draw it on a 1:500.000 chart together with a Power Point presentation. This work al owed drawing important conclusions for the investigation. Concerning possible malfunction or wrong directions provided by the radio altimeter: according to the analysis of communications recordings between pilot and OC and telemetry records, it was possible to establish that the pilot actual y manifested doubts in respect to data provided by the radio altimeter. In relation to this, it is possible to assume that the oscil ating indication was not due to equipment malfunction but to the fact that it was at a lower altitude than that estimated by The radio altimeter showed altitude variations with the surface because it was flying in the proximities of the first abutments of the mountain range. The pilot, confused by these indications, asked OC for confirmation of hil distance and altitude in the area where he was flying. The operator was unable to confirm the information. Directions provided by OC were based on aircraft position obtained trough telemetry and on the experience and geographical knowledge of the area on the part of the OC Upon verification of aircraft debris and available evidence, it is possible to come to the conclusion that the aircraft was technical y apt for the operation. As from recording analysis of the communications between pilot and OC, it was possible to establish that there was no indication of technical failure or inconvenience in the The pilot had the experience to fly this kind of flights since he had already taken He had no experience in night seeding operations, since night seeding operations were not performed in previous campaigns, with this kind of aircraft. As from records, it was possible to establish that at that time he had flown 43:40 With respect to the co-pilot, considering data from activities performed in HS as from DEC 0l, 2004 to accident date, he had flown for 14 hs, of which 05.3 hs were flown with It is possible then to come to the conclusion that, though the pilots were not highly experienced in this kind of aircraft, they were capable of performing the task they were assigned to, independently from other factors to be considered. Since, the commander had already taken part in several campaigns and the co-pilot´s amount of flying hours accounted for Having in mind that the flight was flown during night hours, in good visibility conditions and with variable cloud roofs, the flight rules that the pilot had to fol ow were Instrument Flying Rules according to the procedures described in Flight Regulations and the Airborne cloud seeding sometimes forces pilots to perform instrument flying and, in other occasions, they have to perform the normal visual flying, either in daylight or at night, but always verifying their distance to the convective clouds and keeping flying parameters. In this particular case, at a certain moment, the pilot descended in order to keep eye contact with the clouds and proper conditions for cloud seeding, the lights from the main urbanizations, under cloud roofs which were lower than the minimum level established for the In this respect, during a turn to return to visual flying conditions, he reported to see, to his left, the lights from the city of Tunuyán. This was corrected by the OC operator who, according to the position verified on the radar screen, answered back that the lights were from the city of San Carlos. Though both cities are located on a Provincial Road, the distance between them It is also important to point out the difference in elevation between them; in the proximities of Tunuyán elevations reach 2.851 ft and in the area of San Carlos they extend to Through analysis of the communications, it is possible to come to the conclusion that the pilots would have been excessively focused on the analysis of the task they were performing, and due to this none of them was able to evaluate in the right form the indications that the flight was being carried out at a very low altitude, they did not appraise the radio The circumstances of the flight and the way in which the aircraft impacted on the ground indicate that the impact on the surface occurred without loss of control on the aircraft 2.2.210 The pilot was indeed disoriented, flying at a lower altitude than the one he thought he was descending to, in an area where elevations were higher than the ones he thought he When he reported he was control ing the radio altimeter for possible failure, the Under such circumstance, the pilot could have already lost situational awareness. Development of flight according to data obtained as from telemetry and charts by The first part of the flight adjusted to the procedures described in the Operations Manual for HS. Due to descending cloud roofs, the crew was forced to fly in IMC conditions over the section in the proximities of storm nuclei, which prevented the crew from keeping eye contact with the ground when performing the cloud seeding task. Telemetry charts show a normal HS operation; the crew was unable, though, to This was evident when the pilot reported “we are checking on the radio altimeter……. It reads …. It reads a rather low altitude, so we are going to keep the altimeter at 6.000 ft and we are going to fly northwards just in case”……. and continue with the HS task at Prevailing meteorological conditions in the area were rather complex: low roofs, different cloud levels and convective nuclei in the proximities, on top of that, at night time. As visibility had diminished in the area and in order to maintain eye contact on the ground, the pilot descended; Probably affected by the loss of situational awareness, and not having in mind the existing elevations in the area; he kept his decision to descend to 5.000 ft in order to continue with cloud seeding operations, until he crashed on the ground while he was heading north to fight a storm cel pointed out by the OC operator. Compiled data from information obtained from Radar Control, Telemetry and The information obtained from the room recording system at the OC, suggests that the pilot lost spatial notion, when he misinterpreted the warnings and low altitude indications from the radio altimeter, maintaining an “erroneous” safety altitude quite lower from the one indicated, inadvertently causing loss of indications from the flight instruments he was using, and difficulties in the communications with the OC operator, who, at times, when unable to see information on the screen, at 06:33 hs stated ".Yes, I have problems with the repeater, . yes, According to telemetric records at the OC and data contained in the CAAT - 7B chart, issued by the Air Traffic Direction, when the aircraft was flying in that sector with 5.406 ft altitude, it would actual y have been 1227 ft over the ground, varying its velocity between 128 and 140 kts, with no objections or remarks on the part of the pilot, who went on flying in the area, performing cloud seeding operations for HS, until he was at 5.354 ft altitude, that is, 1.014 From the evaluation between aircraft position and cartography, it is possible to infer that the loss of indications from flight instruments and communications with the OC operator, would coincide with low altitude and interference of neighboring hil s between repeater This situation was not detected by the crew, but was indeed detected by the OC Operator who warned the pilot by saying at one section of the flight “that . according to a map I have here, there are some peaks of 1500 meters in that area, five thousand feet so it is not …it is not advisable. You should go up again over the six thousand.” The pilot did not pay attention to the suggestions, since due to lack of visibility and in order to obtain proper conditions for cloud seeding he descended again to 5.300 It; already without safety altitude margin and with probable indications of low flight in the radio altimeter. In these conditions, he flew 20 more minutes until the aircraft crashed against the Continuous altitude and course shifts during the flight in order to position the aircraft favorably for HS activities and flying alternatively in and out the clouds originated a loss An aspect considered to be contributive to the loss of situational awareness is the fact that the pilot performed multiple tasks in a flight with very special characteristics. Another important aspect is the scarce experience of both men in the type of When the pilot control ed the radio altimeter, he was not able to appraise in the correct way the seriousness of the information since the indications showed that they were flying at a constantly reducing altitude. Even the linear distribution of aircraft debris on the ground surface and the distance it traversed until it final y stopped, make it evident that the aircraft was not out of control and that the impact surprised the crew since it was planar and on a ground of very few The previous expressions constitute the foundation which chal enged the human factor, as an element directly related to the accident and then it can be assumed that it was “the consequence of an impact on the surface without loss of control” (Control ed Flight Into Terrain In this type of accidents, the pilot believes the flight is being carried out normal y until, suddenly, a col ision into terrain takes place. During investigation, it was possible to establish that, due to the constant changes in meteorological conditions and to the necessity for day and night flights, it was difficult to supervise the planning and execution of flights In respect to that, planning and supervising takes place up to the execution of the flight, due to meteorological forecasting, but once the flight has started, execution is on the The Operations Manual foresaw an assistant for airborne operations at the OC who had to be a pilot, though such a shift had not been implemented, the OC operator warned the pilot appropriately about the existence of elevations which affected flight security. In the same way, there was no specification of the assistant functions at the MOE and the specific procedure for night seeding. Crew and aircraft were authorized to perform the flight for HS. The accident is not related to aircraft technical aspects Crew had difficulties to be aware of their geographical location, aircraft flying altitude and their relation with respect to surface. It is possible to relate the accident to a loss of situational awareness on the part of Telemetry equipment and communications records from OC al owed reconstructing the flight, until they lost contact wit the aircraft. The pilot had little experience in the kind of aircraft which suffered the accident but he indeed had experience in the kind of operation because he had taken part in previous Supervising the flight was difficult due to the kind of flight and the lack of a pilot According to the characteristics of the accident and the conditions under which it took place, it is possible to consider it as an impact against the surface on a control ed flight. Some differences were detected as regards safety altitudes in the accident area, between chart CAA 7 issued by Air Traffic Direction and the chart ONC 2-23 issued by Defense The procedure for night time cloud seeding and the function of the pilot assistant HS aircrafts had different avionics configurations. Air traffic management was delegated by the ATC to the OC during cloud seeding Prevailing meteorological conditions in the area were complex, low roofs, clouds at different levels in the proximities of convective nuclei and, on top of that, nocturnal. During a night hail suppression flight, at airborne cloud seeding phase, the aircraft crashed against the surface in control ed flight (CFIT), due to the loss of situational awareness of the pilot who descended under safety altitude. Difficulty to exert supervising of this type of flights due to the flight own characteristics. To the Agriculture and Natural Hazards Prevention Direction of the Province of HS flights must be considered dangerous because of the unfavorable meteorological conditions under which they have to be carried out, at day time as wel as night time, either on instruments or visual y . Therefore, it is recommended to adopt al the necessary precautions so that involved crew members receive proper training, taking into account that these flights are performed in areas very close to the mountain ranges and under constant course and altitude changes, which in the end bring about complex situations for the crew In the same way, it is recommended to emphasize on the management program for available human resources (CRM) on future campaigns for HS, and the appointment of an assistant for airborne operations in the OC, according to the specifications of the MOE, describing his functions very specifical y, so as to contribute to operational safety. 4.1.3 If possible, to incorporate to meteorological radar presentation on ground base, the location of the highest obstacles in the areas which include the “zones” which can affect flight safety and development; so as to facilitate interaction between OC operator and aircraft To consider the necessity for establishing a close fol owing up of flight operation management for HS, adopting proper measures so that pilot staff is managed according to the verified techniques from CRM, focusing on personnel training and establishing efficient procedures to contribute to operational safety based on their own cumulated experience. Physical or legal persons to whom recommendations issued by Civil Aviation Accident Investigation Board are addressed, must report to Accident Prevention Commission within a term no longer than SIXTY (60) working days, counted as from reception of Final Report and the Regulation approving it, the fulfil ment of the actions put under their responsibility. (Regulation Ner 51/02 Air Regions Commander – July 19, 2002- published on the Official Mentioned information should be addressed to: Civil Aviation Accident Prevention Commission Operative Investigator: Mr. Aldo COMISSO. Technical Investigator: SM Pedro BERTACCO. IN VIEW of the proceedings initiated as a consequence of the aviation accident of a CESSNA aircraft, model C-340, register N5790M, occurred 38 km. SSE of Pareditas location, County of San Carlos, Province of Mendoza, on February 07, 2005 at 06:41 (UTC), taking into account the instructed investigation, its corresponding final report and That the Final Report provided covers al the aspects pertinent to investigation, register and analysis of the facts, conclusions and recommendations on safety. That it is of convenience to publish and divulge this Final Report, which sums up the procedures of the investigation of the occurred fact, because it is estimated as useful to contribute to prevent the repetition of similar accidents. That getting to know the causes of such accidents and the proper use of that knowledge, wil bring about benefits for the aeronautic activities and particularly operational safety. That Decree 934/70, articles 14º and 15º bestow faculties to solve on aviation accidents THE PRESIDENT OF THE CIVIL AVIATION ACCIDENT INVESTIGATION BOARD 1º) Approving and attaching to the herein the Final Report which resolves on the procedures, in technical investigation, performed due to the accident occurred to the TLA License Ner 44.508 Gabriel Alejandro GIRALDA and TLA Pilot License Ner 42.138 Alejandro José SCHAAF, who suffered character “F-MORTAL" injuries and aircraft which resulted in "D-DESTROYED" damages. 2º) Addressing a copy of this Regulation and Final Report to the Juzgado Federal Nº 3 Mendoza, Secretaría Penal “E” in charge of Dr. Ricardo BENTO. 3º) Addressing a copy of this Regulation and of the Final Report for the knowledge and consideration to: National Transportation Safety Board - NTSB Airworthiness National Director. Aeronautic Authorization Director. President of the CRA Accident Prevention Commission. Agriculture and Natural Hazards Prevention Direction of the Province of Mendoza 4º) To publish a summary of the Final Report, at the news Bul etin and on JIAAC web page, and to send an issue to the Electronic Library of the OACI, an issue to the Aeronautic National Library and file it.


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Communication Skills for Health Care Providers Lesson 3 of 8 Read Interpretive Learning Objectives At the end of this lesson, you will be able to: 1. Identify and comprehend recorded information, e.g., employee manuals, patient procedure guides, job duty lists. Introduction Health Care Workers must have the ability to interpret reading material at the work site. In

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