Airport (less than 10 km from airport)

The pilot's continued VFR flight into instrument meteorological conditions, and his failure to maintain altitude/clearance above the ground, resulting in a collision with snow and ice covered terrain during the final approach phase of a VFR landing. Factors in the accident were whiteout conditions and snow-covered terrain.

The pilot's failure to fly a stabilized, published instrument approach procedure, and his failure to maintain adequate airspeed which led to an aerodynamic stall.

It was determined that the aircraft was operated in illegal conditions at the time of the accident. On board were 23 skydivers while the aircraft was certified for 12 skydivers maximum. At the time of the accident, the total weight of the aircraft was 618 kilos above MTOW and the CofG was well beyond the rear limit (around 35%), especially when the 11 skydivers moved through the rear of the cabin. Some of the skydivers were seating on the floor and one was in the toilets.

The pilot's failure to follow the instrument approach procedure, which resulted in an early descent into trees and terrain. Factors included the low ceiling and the night lighting conditions.

It was determined that the right engine failed during initial climb following the rupture of a turbine ball bearing due to poor lubrication.

The following findings were identified:
Air Traffic Services:
1. ATS was not available at Baucau at the time of the occurrence.
2. There was no procedure in place to provide flight crews of aircraft engaged in non-UN operations with an altimeter subscale setting for Baucau at the time of the occurrence.
Organisational factors:
1. Neither the Lao-based company, nor the Cambodian-based company, sought the consent for the proposed sublease, dated 18 November 2002, and accordingly the inferred sublease had not been finalised.
2. The Cambodian-based company was not the operator of the aircraft for the occurrence flight.
3. The Lao PDR was the State of Registry and State of the Operator.
4. The Lao DCA was responsible for the continued surveillance of the operator to ensure that the required standards of operation were maintained.
5. The operator provided flight crews with inflight CFIT avoidance procedures in its operations manual.
CFIT risk exposure:
1. The planned flight from Macau to Baucau was exposed to moderate risk of a CFIT event, based on historical CFIT data and the Transport Canada simple method of risk analysis.
2. The destination risk factors, type of operation, area of operation, weather conditions, and flight crew non-compliance with published procedures increased the CFIT risk exposure of the planned flight to an above-average level.
3. The consequences of the accident were catastrophic and resulted in loss of human life and damage to property and the environment.
4. Those catastrophic consequences resulted from the flight crew’s disregard of established procedures; that disregard bypassed all the safety criteria and inbuilt risk treatments in the design of those procedures and steadily increased the CFIT risk exposure to an extreme level during the latter stages of the flight.
Significant factors:
1. The flight crew did not comply the published non-precision instrument approach and/or missed approach procedures at Baucau during flight in instrument meteorological conditions.
2. The flight crew conducted user-defined non-precision instrument approaches to runway 14 at Baucau during flight in instrument meteorological conditions.
3. The pilot in command permitted the aircraft to descend below the MDA(H) published on both the Jeppesen and CAD runway 14 instrument approach charts during flight in instrument meteorological conditions.
4. The flight crew did not recognise the increased likelihood and therefore risk of CFIT.
5. The flight crew did not recognise or treat that risk in a timely manner.

The pilot's failure to maintain an adequate altitude clearance from mountainous terrain. Contributing factors were dark night conditions, mountainous terrain, and the pilot's diverted attention.