Investigation Summary
The flight was a short hop from Málaga to the Spanish exclave of Melilla. As the aircraft approached Cape Tres Forcas, it encountered instrument meteorological conditions (IMC) with low clouds and fog, which are common in the area due to the local topography. Despite the poor visibility, the crew continued a descent that deviated from the established arrival procedures. The investigation revealed that the pilots descended below the minimum safe altitude for the sector. During the final moments, the GPWS issued a 'terrain' alert followed by a 'Whoop, whoop, Pull Up' command, but the crew did not take corrective action to climb. The aircraft struck the side of a mountain in the Boumahfouda region of Morocco, approximately 12 kilometers from Melilla.
Final Conclusions
The investigation concluded the accident was a classic Controlled Flight Into Terrain (CFIT). The primary causes were the crew's failure to follow the standard arrival procedure, their decision to descend below the minimum safe altitude in IMC, and a lack of adequate crew coordination. Furthermore, the crew failed to apply company procedures regarding the mandatory response to GPWS alarms.
Video Analysis
El Accidente más trágico de la aviación en Melilla | Vuelo 4101 — A documentary covering the tragic crash of PauknAir Flight 4101, a BAe 146 that crashed in Morocco while approaching Melilla on September 25, 1998.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Systems & Failure Modes
GPWS
Ground Proximity Warning System; provided two 'terrain' alerts that were ignored by the crew.
Instrument Meteorological Conditions (IMC)
The weather conditions required the crew to fly solely by reference to instruments, but they descended below safe limits without visual contact.
Interesting Facts
- 01The aircraft was the seventh BAe 146 ever built (MSN E1007), originally delivered to British Airways in 1983.
- 02The crash site was located at Cape Tres Forcas in Morocco, a headland near Melilla known for frequent fog.
- 03The investigation confirmed the aircraft was fully functional prior to the impact.
- 04All 34 passengers and 4 crew members perished in the accident.
Safety Actions & Advisories
GPWS Training Reinforcement
The investigation emphasized the necessity of strict adherence to GPWS warnings, mandating an immediate climb regardless of the crew's perceived situational awareness.
Arrival Procedure Compliance
Recommendations were made to ensure crews strictly follow published arrival procedures and minimum safe altitudes, especially in mountainous terrain under IMC.