Pilot error, poor maintenance caused Robredo plane crash, official report says

MANILA, Philippines – The Civil Aviation Authority of the Philippines (CAAP) found pilot error and poor aircraft maintenance as the causes of the airplane crash that killed Interior Secretary Jesse Robredo and two others last August.
In a press conference Tuesday, President Benigno Aquino III announced the results of the CAAP investigation of the airplane crash off the coast of Masbate that killed Robredo and pilots Captain Jessup Bahinting and flight student Kshitiz Chand.
“When I read the initial report, I felt a mixture of sadness and dismay,’’ the President said before the committee released details of its investigation report in Malacañang.
The committee, chaired by Capt. Amado Soliman Jr., concluded that when the right hand engine became problematic, Captain Bahinting  committed an error by continuing to “fly away from Cebu’’ instead of turning back. The plane was flying from Cebu to Naga City when it crashed.
Aquino said that Aviatour, the company that owned and operated the ill-fated Piper Seneca carrying Robredo from Mactan Airport last August 18 was found to have lapses in its compliance with requirements of the CAAP.
CAAP said in the report that poor maintenance of the airplane’s right engine had caused it to stall.
CAAP investigators also found that Aviatour management had allegedly connived with CAAP inspectors to allow the aircraft to pass
“The pieces of evidence pointed to one thing: if some people did their job, if the rules of the industry were followed, if those involved were only faithful to their obligations, the tragedy could have been avoided,’’ he continued.
Aquino said Bahinting lacked the proper experience and training for “one-engine inoperative emergency’’ even though some said he was an expert pilot.
“It’s clear he failed to fly the plane safely on one operating engine. Apart from this, 23 minutes after taking off from Mactan, he became aware that the engine malfunctioned, but instead of turning back, they flew ahead to Naga,’’ he said.
“They were airborne for 70 minutes before the plane crashed. That means, if they had turned back immediately to Mactan, there was a high possibility the accident could have been avoided,’’ he continued.
The Piper Seneca, piloted by Bahinting, took off from the Cebu International Airport for Naga City at around 3 p.m. on Aug. 18. At about 4:25 p.m., it crashed into the waters off Masbate City, killing Robredo, Bahinting and Nepalese student pilot Kshitiz Chand.
Robredo’s aide, Senior Insp. Jun Abrazado, survived. He swam out through an opening in the plane and was rescued by a fisherman.
Malacañang organized a state funeral for Robredo. It has announced national days of mourning from Aug. 21, when Robredo’s body was recovered, until his interment.
The CAAP later created a special committee, composed of representatives from various sectors of the aviation industry, to investigate the crash.
The investigating committee, chaired by Capt. Amado Soliman Jr., cited several key errors by the pilot, but the most blatant was: “When the right hand engine became problematic, he continued to fly away from Cebu instead of turning back.’’
While one engine had problems, both engines were still functioning and continued to do so for another 30 minutes. And Cebu has the most modern air navigation and communication equipment, the longest runway, the widest airstrip, the most advanced and most trained crash, fire and rescue equipment and personnel within reach, it added.
“Mostly, it is the pilot’s inability to control that aircraft on an emergency situation where he lost one engine,’’ Soliman said.
The other errors were:
* pilot had no previous experience on the flight route;
* pilot lost situational awareness with regard to the plane’s relative position to Masbate Airport;
* pilot’s license renewal did not cover “one engine inoperative emergency’’ during his proficiency flight;
* upon entering Masbate airspace, the pilot undertook improper approach procedures, such as flight approach heading pattern, premature extension of landing gear and flaps, and improper approach maneuver;
Aquino said Bahinting’s premature extension of the landing gear and flaps ran counter to the Piper Seneca Flight Manual Procedures for twin-engine planes.
“According to the experts, this contributed to the ‘drag,’ that slowed down the plane until this could no longer be controlled and crashed,’’ he said.
Accordingly, pilot error caused the crash, and pilot Bahinting “improperly handled a one-engine inoperative emergency,’’ Soliman said during a PowerPoint presentation.
“Among airline pilots, single engine is just a routine maneuver. I don’t know why in the general aviation, there seems to be a problem. Even if you lose an engine–a twin or a multi-engine aircraft–it doesn’t have to end in an accident. But it will end in an accident if the pilot lacks the training to handle that aircraft during emergency situation flight having lost one engine,’’ he later said in response to reporters’ questions.
“As I was saying, it could have gone back to Cebu and still landed with two engines because the engine conked out 37 minutes after the first indication of trouble. So he was only 23 minutes out of Mactan, it could have very well gone back to Mactan and land with  two engines,’’ he continued.
In its findings on the plane, the committee concluded that the right hand engine experienced “hard starting’’ after the installation of the overhauled propeller, but this was not recorded in the aircraft logbook.
Specifically, two screws that held the idler gear shaft in place had “material failure.’’ The bent edge of the lock plate was supposed to lock the screw in place was also found broken, it added.
The committee concluded that the stoppage of the right-hand engine caused the emergency, the stoppage was “likely caused’’ by intermittent fuel supply and erratic engine firing; and the intermittent fuel supply was caused by parts failure due to bad maintenance.
It also noted that Aviatour was not certified by the aircraft manufacturer and by CAAP to conduct maintenance on the aircraft.
“The checks and balances of Aviatour were also found wanting. The investigation showed that Aviatour’s own mechanics conducted checks on the Piper Seneca when they were not authorized by the manufacturer,’’ the President said.
The committee also found flaws in the management of Aviatour, including improper issuance of airworthiness certificate.
Airworthiness inspector Fernando Abalos approved the test flight permit for renewal for airworthiness certificate for the ill-fated Seneca plane on Jan. 7, 2012, but there was no record on the aircraft logbook for the test flight, the committee said.
A check with Mactan-Cebu International Airport Flight Operations Log showed that no flight plan for the plane was filed on that day, it added.
Capt. Federico Omolon, Aviatour’s flight instructor, testified that Bahinting asked him to sign the flight test report even though he did not fly the plane on Jan. 7 this year, the committee said.
On Jan. 17 this year, Abalos signed and endorsed the company’s application for airworthiness certificate renewal of the ill-fated plane, and an entry in the Civil Aviation Safety Oversight Reporting and Tracking database showed that the documents for such renewal had been reviewed by Abalos.
On Feb. 2, the certificate of airworthiness was released to Armand Gozum of Aviatour, but this was pre-dated Jan. 7, 2012.
“Captain Bahinting connived with airworthiness inspector Abalos to expedite the processing and approval of the certificate of airworthiness,’’ the committee concluded.
“It was clear that they committed deception and fraud. The cost: the life of three people,’’ the President said. “This is a symptom of anomaly in a system that has long prevailed, and which we are now addressing. We will not allow this system to continue. That’s why evidence would continue to be gathered to hold accountable those who have shortcomings on the part of Aviatour and even CAAP.’’
Interior Secretary Manuel Roxas II, Robredo’s successor, said he felt “sad” over the reported connivance of Bahinting with CAAP officials.
The President gave the following instructions to the transport officials:
*Audit the permits and licenses issued by CAAP, and recall those that violate standards of the Philippine Civil Air Regulations
* Strengthen the rules for the operations of the flying schools, air taxi, approved maintenance organizations.
*Craft additional mechanisms to strictly enforce industry regulations.
“We don’t want this tragedy to happen to anyone,’’ he said. “More than mourning, more than honor and recognition, Jesse would want us to learn from the tragedy that befell him. Let’s not allow his passing to come to naught.’’
With the release of the investigation report, CAAP director general William Hotchkiss III ordered the creation of a special investigating body to look into administrative and criminal culpabilities of CAAP and Aviatour’s personnel.
“Aviatour has been suspended–its full operation before–but not its personnel, not yet. We need to go through a due process thing,’’ Hotchkiss said.
In consultation with Assistant Director General (Abdiel) Fajardo, Hotchkiss said he would act on the matter of suspending CAAP personnel within the week.
“Whatever is turned up by the investigating body will definitely also feel the brunt of the full implementation of Philippine Civil Air Regulations,’’ he said. With a report from TJ Burgonio