Investigation Summary
The flight was a non-scheduled commercial air transport operation transporting a patient and his wife from Dipolog to Manila. While tracking the 170 radial at 25 DME (approximately 46 km) from Ninoy Aquino International Airport, the aircraft was cleared to descend from 9,000 feet to 5,000 feet. Shortly after this clearance, radar contact was lost. Witnesses on the ground observed the aircraft trailing smoke and banking steeply before it plummeted. The distribution of debris across the Miramonte Village subdivision indicated that the aircraft suffered an in-flight breakup. The investigation, supported by the Australian Transport Safety Bureau (ATSB) for data recovery from the fire-damaged Fairchild A100S cockpit voice recorder, determined that the crew encountered hazardous atmospheric conditions. The combination of severe turbulence and a breakdown in Crew Resource Management (CRM) prevented the pilots from recovering the aircraft from an upset condition.
Final Conclusions
The Civil Aviation Authority of the Philippines (CAAP) concluded that the primary cause was a loss of control in-flight (LOC-I) resulting from adverse and hazardous atmospheric turbulent weather, which led to an in-flight breakup. Contributory factors included the flight crew's failure to maintain situational awareness and a breakdown in CRM to apply appropriate emergency procedures. The final report was released in October 2023.
Video Analysis
RP-C2296 PLANE CRASH SEPTEMBER 01, 2019 LAGUNA — News coverage and footage from the crash site at the Agojo Resort in Pansol, Laguna, showing the aftermath of the Lionair King Air 350 accident.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Systems & Failure Modes
Fairchild A100S Cockpit Voice Recorder
The CVR was recovered from the wreckage in a severely fire-damaged state and required specialist data recovery in Canberra, Australia.
Airframe Structure
The aircraft experienced structural failure (in-flight breakup) due to aerodynamic loads exceeding design limits during a loss of control event in turbulence.
Interesting Facts
- 01The aircraft was a Beechcraft B300 King Air 350, serial number FL-196, manufactured in 1998.
- 02All nine occupants, including two pilots, a patient, his wife, and medical staff, were fatally injured.
- 03The crash occurred during the monsoon season under Instrument Meteorological Conditions (IMC).
- 04The aircraft had previously been involved in a runway excursion in 2009 while operated by INAEC.
- 05Following this accident and a subsequent Lionair Westwind crash in 2020, the CAAP temporarily grounded the operator's entire fleet.
Safety Actions & Advisories
CRM Syllabus Enhancement
CAAP recommended the operator include Upset Prevention and Recovery Training (UPRT) and Threat and Error Management (TEM) in their CRM syllabus.
Pilot Currency Oversight
The operator was directed to review policies regarding the utilization of pilots not regularly employed and ensure compliance with PCAR 8.4.1 regarding pilot currency.
Location
ACCIDENT SITE · Coordinates taken from the official investigation report.