Investigation Summary
The flight originated in Manila and made an unscheduled stop at Tacloban to deliver a spare tire for a grounded Cebu Pacific DC-9 (RP-C1506). After a brief nine-minute turnaround, the aircraft departed for Cagayan de Oro. The pilots were flying under Visual Flight Rules (VFR) despite marginal weather conditions including clouds and strong winds in the mountainous region. The aircraft deviated from the standard airway (W-10) to follow a more direct, non-standard path toward the Lumbia Airfield. This shortcut, combined with poor visibility, led the aircraft to be approximately two to three kilometers off its intended track when it struck the 2,234-meter high Mount Sumagaya at an elevation of roughly 2,100 meters. Investigation revealed significant deficiencies in the airline's operational controls and pilot training programs.
Final Conclusions
The investigation concluded the primary cause was Controlled Flight Into Terrain (CFIT) resulting from the aircraft being off-course in poor visibility. Contributing factors included inadequate pilot training and practices, poor operational controls by Cebu Pacific, and non-compliance with crew training procedures. The investigation also noted that the operator was using aircraft components beyond their expiration dates and that more than half of the analyzed company procedures were deficient.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Captain Paulo Justo
First Officer
First Officer Erwin Golla
Systems & Failure Modes
Visual Flight Rules (VFR)
The pilots were operating visually rather than using instruments, which became hazardous when clouds obscured the mountainous terrain.
Operational Controls
The investigation found that Cebu Pacific's internal oversight and procedural compliance were significantly deficient.
Interesting Facts
- 01The aircraft was 30 years old at the time of the accident, having first been delivered to Air Canada in 1967.
- 02The crash remains the second deadliest aviation accident in Philippine history.
- 03The aircraft was approximately 2 to 3 kilometers off its intended course at the time of impact.
- 04A memorial structure 20 meters tall was inaugurated at the crash site on February 2, 2021.
- 05The flight was carrying 99 passengers, including five children and six foreign nationals.
Safety Actions & Advisories
Airline Grounding
Following the accident, the Philippine government temporarily grounded Cebu Pacific Air to conduct a safety audit and review of the airline's operations.
Training Reform
The investigation mandated a complete overhaul of pilot training and operational procedures at Cebu Pacific due to identified deficiencies in 17 analyzed procedures.
Known Controversies & Unanswered Questions
Unscheduled Stop and Route Deviation
Reference ↗There was initial public debate regarding whether the unscheduled stop in Tacloban to deliver tires contributed to the pilots' decision-making or pressure to maintain the schedule, though the official cause focused on the navigational error and CFIT.