Nas Guantanamo Bay Airport
Aircraft Accident/Incident Report

Guantanamo Bay Cuba
Wednesday, August 18, 1993 16:56 EDT

THE AIRPLANE COLLIDED WITH TERRAIN APRX 1/4 MI FROM THE APPROACH END OF THE RUNWAY AFTER THE CAPTAIN LOST CONTROL OF THE AIRPLANE. FLIGHTCREW HAD EXPERIENCED A DISRUPTION OF CARCADIAN RHYTHMS AND SLEEP LOSS; HAD BEEN ON DUTY ABOUT 18 HRS AND HAD FLOWN APRX 9 HRS. CAPT DID NOT RECOGNIZE DETERIORATING FLIGHTPATH AND AIRSPEED CONDITIONS DUE TO PREOCCUPATION WITH LOCATING STROBE LIGHT ON GROUND. STROBE LIGHT, USED AS VISUAL REFERENCE DURING APPROACH, INOPERATIVE; CREW NOT ADVISED. REPEATED CALLOUTS BY THE FLIGHT ENGINEER STATING SLOW AIRSPEED CONDITIONS WENT UNHEEDED BY THE CAPT. CAPT INITIATED TURN FROM BASE LEG TO FINAL AT AIRSPEED BELOW CALCULATED VREF OF 147 KTS, AND LESS THAN 1,000 FT FROM THE SHORELINE, AND HE ALLOWED BANK ANGLES IN EXCESS OF 50 DEG TO DEVELOPE. STALL WARNING STICK SHAKER ACTIVATED 7 SECS PRIOR TO IMPACT, 5 SECS BEFORE AIRPLANE REACHED STALL SPEED. NO EVIDENCE TO INDICATE CAPT ATTEMPTED TO TAKE PROPER CORRECTIVE ACTION AT THE ONSET OF STICK SHAKER. OPERATOR'S MANAGEMENT STRUCTURE AND PHILOSOPHY WERE INSUFFICIENT TO MAINTAIN VIGILANT OVERSIGHT AND CONTROL OF THE RAPIDLY EXPANDING AIRLINE OPERATION.

THE IMPAIRED JUDGEMENT, DECISION-MAKING, AND FLYING ABILITIES OF THE CAPTAIN AND FLIGHTCREW DUE TO THE EFFECTS OF FATIGUE; THE CAPTAIN'S FAILURE TO PROPERLY ASSESS THE CONDITIONS FOR LANDING AND MAINTAINING VIGILANT SITUATIONAL AWARENESS OF THE AIRPLANE WHILE MANEUVERING ONTO FINAL APPROACH; HIS FAILURE TO PREVENT THE LOSS OF AIRSPEED AND AVOID A STALL WHILE IN THE STEEP BANK TURN; AND HIS FAILURE TO EXECUTE IMMEDIATE ACTION TO RECOVER FROM A STALL. ADDITIONAL FACTORS CONTRIBUTING TO THE CAUSE WERE THE INADEQUACY OF THE FLIGHT AND DUTY TIME REGULATIONS APPLIED TO 14 CFR, PART 121, SUPPLEMENTAL AIR CARRIER, INTERNATIONAL OPERATIONS, AND THE CIRCUMSTANCES THAT RESULTED IN THE EXTENDED FLIGHT/DUTY HOURS AND FATIGUE OF THE FLIGHTCREW MEMBERS. ALSO CONTRIBUTING WERE THE INADEQUATE CREW RESOURCE MANAGEMENT TRAINING AND THE INADEQUATE TRAINING AND GUIDANCE BY AMERICAN INTERNATIONAL AIRWAYS, INC., TO THE FLIGHTCREW FOR OPERATIONS AT SPECIAL AIRPORTS, SUCH AS GUANTANAMO BAY; AND THE NAVY'S FAILURE TO PROVIDE A SYSTEM THAT WOULD ASSURE THAT THE LOCAL TOWER CONTROLLER WAS AWARE OF THE INOPERATIVE STROBE LIGHT SO AS TO PROVIDE THE FLIGHTCREW WITH SUCH INFORMATION. (NTSB REPORT AAR-94/04, ADOPTED 5/10/94)