Investigation Summary
The accident began during the takeoff roll on Runway 05 when air traffic controllers observed the forward baggage hold door swing open. The aircraft, a Let L-410UVP-E3 (MSN 87 20 01) manufactured in 1987, had accumulated 2,982 airframe hours and 4,154 cycles at the time of the accident. It was carrying 19 passengers and 2 crew. The crew, noticing the technical issue, declared an emergency and requested a return to the airport. While maneuvering for a return, the aircraft turned to the left despite being cleared for a right downwind leg, and its speed decayed significantly. Investigators found that the crew had selected full flaps (42 degrees), a configuration that created immense drag. Although witnesses reported seeing fire during takeoff, examination of the engine wreckage confirmed no evidence of fire prior to impact. The investigation was hampered by the absence of a Cockpit Voice Recorder and Flight Data Recorder, forcing investigators to rely on wreckage analysis and controller testimony. Propeller analysis confirmed the engines were producing power at impact, ruling out engine failure. The investigation highlighted severe fatigue as a factor, noting the Captain had worked 15 consecutive days without the scheduled rest period required by his 7/7 rotation. Additionally, the lack of weight and balance documentation suggested the aircraft might have been operating above its maximum takeoff weight, further reducing the stall margin during the emergency turn.
Final Conclusions
The Haitian investigative commission concluded the primary cause was a stall during the approach phase due to the loss of airspeed required to maintain control. Contributing factors included poor Crew Resource Management (CRM), the inappropriate use of maximum flaps (42 degrees) during the emergency, insufficient altitude, and lack of coordination. The opening of the cargo door acted as the initiating event, while pilot fatigue and possible aircraft overweight were cited as significant underlying factors.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
American national; reported to be fatigued due to interrupted 7/7 work schedule.
First Officer
Spanish national.
Systems & Failure Modes
Cargo Door
The forward baggage hold door opened during takeoff, creating an emergency situation that distracted the crew and increased drag.
Flaps
The crew extended the flaps to the maximum 42 degree setting, which significantly increased drag and contributed to the stall at low altitude.
Interesting Facts
- 01The aircraft was not equipped with a Cockpit Voice Recorder (CVR) or Flight Data Recorder (FDR).
- 02Post-crash examination revealed the flaps were in the 'full down' 42 degree position.
- 03The Captain had worked 15 consecutive days (August 9 to 24) without his scheduled rest period.
- 04No weight and balance documentation existed for the flight, making the exact takeoff weight unknown.
- 05Propellers were found to be rotating at high revolutions at impact, not in the feathered position.
Safety Actions & Advisories
Crew Fatigue Management
The investigation emphasized the need for strict adherence to crew rest schedules, noting the Captain's fatigue due to working 15 consecutive days without the required 7/7 rotation rest.
Weight and Balance Oversight
The lack of weight and balance documentation for the flight led to recommendations for improved oversight of aircraft loading procedures to ensure operations remain within maximum takeoff weight limits.