Hamilton

Fuel exhaustion.

The pilot continued visual flight into instrument weather conditions that resulted in the inflight collision with a river bank. Factors were reduced visibility and dark night.

Failure of both engines after the crew failed to realize that the fuel selector was positioned on the wrong fuel tank. The following contributing factors were reported:
- After the second engine failure, the crew failed to plan effectively for a forced landing, and ultimately failed to maintain controlled flight,
- Probable factors contributing to these failures include: workload, time pressure, unfamiliarity with the situation in which they found themselves and inexperience on type.

Failure of the first officer (co-pilot) to maintain control of the aircraft after becoming spatially disoriented, and his exceeding the design stress limits of the aircraft. Factors related to the accident were: the lack of two pilots in the cockpit, darkness, and instrument meteorological conditions (IMC) at flight altitude.

Improper IFR operation on part of the pilot. The following factors were reported:
- Collision with trees,
- Fog,
- Descended below MDA in marginal weather conditions.

The primary cause of this accident was due to Operator Error in that the pilot descended below minimums in such a manner that the aircraft struck trees, and subsequently became doubtful of his position to the point of being lost due to failure to use all approach and navigational aids which further compounded his emergency. Although it is primarily the responsibility of the aircraft commander for the safe conduce of flight, it is also the duty and responsibility of the co-pilot to advise the pilot in sufficient time, prior to reaching minimums or a dangerous condition to allow him to check the rate of descent so as not to descend below minimums or hit the ground or obstructions. The pilot failed to adequately brief the flight crew for the type of approach to be made and missed approach procedures for that particular approach.

The probable initial cause of the accident was the failure of the pilot to carry out the normal climb-out procedure following take-off from runway 34 on a flight to Bermuda and his having made a turn to the left instead of to the right, thus flying into the mountains instead of turning out to sea.
The possibility of the aircraft having been forced to make a left turn may be disregarded since, from examination of the wreckage, it appears that no mechanical failure occurred.
The procedure to be followed had been duly explained to the crew both at the briefing and in the instructions which were certainly given by the tower. It is pointed out, moreover, that the chart of Lajes in the route manual supplied to the crew clearly shows that all turns must be made towards the Northeast.
The question of a right turn following take-off appears to have been deemed a secondary matter by the crew members who called at the briefing office. They simply established that they had to proceed directly to Ponto Sul in order to avoid a collision with the mountains, the highest point of which reached 7 615 feet.
From the heading presumed to have been flown by the aircraft before it crashed, it is quite apparent that the pilot did, in fact, intend to proceed to Ponto Sul. He appears not to have realized, however, that to do so he had to turn eastward towards the sea and not to the west over the land.
It is necessary to mention that, according to his company, this was the first time that the captain had landed at Lajes and that at Santa Maria, where he had already landed several times, the take-off procedure for flights towards the Northwest in the direction of Bermuda also involves a turn towards the sea. The turn at Santa Maria is made to the left, however, as the airport is located on the extreme west of the island.
The point known as Ponto Sul is shown on the reproduced 1:l 000 000 chart at Fig. 30. Examination of this chart will immediately explain the reason for the adoption in the Azores control area of the standard procedure 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 Ihla Terceira, the requirement, for reasons of safety, to turn to the east and out to sea in order to avoid the mountains on the island needs no special comment, being obvious in view of the nature of the terrain.