E PLURIBUS UNUM

NATIONAL TRA SPORTATIO

N

B OARD

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Aircraft Accident Brief

Accident Number: IAD05FA023 

Aircraft and Registration: CASA C-212-CC, N960BW 

Location: Bamiyan, Afghanistan 

Date: November 27, 2004 

Adopted On: November 8, 2006 

HISTORY OF FLIGHT 

On November 27, 2004, about 0820 Afghanistan time,1

 a Construcciones Aeronauticas 

Sociedad Anonima C-212-CC (CASA 212) twin-engine, turboprop airplane, N960BW, 

registered to Aviation Worldwide Services, LLC, and operated by Presidential Airways, Inc., of 

Melbourne, Florida, collided with mountainous terrain in the vicinity of the Bamiyan Valley, 

near Bamiyan, Afghanistan.2 The Department of Defense (DoD) contract flight was operated 

under the provisions of 14 Code of Federal Regulations (CFR) Part 135, with a company flight 

plan filed. Daylight visual meteorological conditions (VMC) prevailed. The captain, the first 

officer, and the mechanic-certificated passenger, who were U.S. civilians employed by the 

operator, and the three military passengers, who were active-duty U.S. Army soldiers, received 

fatal injuries. The airplane was destroyed. The flight departed Bagram Air Base (OAIX), 

Bagram, Afghanistan, about 0738. 

Presidential Airways provided transport services for U.S. military personnel and cargo 

within Afghanistan, Uzbekistan, and Pakistan under an Air Mobility Command (AMC) contract 

with the DoD.3 According to Presidential Airways’ program site manager, he briefed the captain on 

the mission itinerary about 0700. The purpose of the mission was to transport military cargo4

 to 

Farah, Afghanistan (OAFR), and the three military passengers were traveling in a “space available” 

status.5

 The flight was to depart OAIX and fly to OAFR, and then fly to Shindand, Afghanistan 

 

1

 Afghanistan time is coordinated universal time plus 4 hours 30 minutes. All times are reported in Afghanistan 

time, unless otherwise indicated. 

2

 At the request of the Transitional Islamic Government of Afghanistan, Ministry of Civil Aviation & Tourism, 

the National Transportation Safety Board accepted delegation of the accident investigation in accordance with 

paragraph 5.1 of Annex 13 to the Convention on International Civil Aviation. 

3

 The AMC contract was FA4428-04-D-0036, dated September 20, 2004. 

4

 The cargo was 400 pounds of 81-mm mortar illumination rounds. 

5

 According to the operator, the cargo mission flights would attempt to accommodate passengers as requested 

by the military when airplane space was available and loading allowed. Military logistics personnel were responsible 

for manifesting the passengers and cargo loads. 
2

NTSB/AAB-06/07 

(OASD), for fuel before returning to OAIX. The briefing included the expected cargo and passenger 

loads, as well as military intelligence information that there were no significant threats for the 

mission. The program site manager and the captain discussed the area weather forecast, which 

primarily consisted of VMC with the possibility of blowing dust at OASD, and they agreed that 

Kandahar, Afghanistan (OAKN), would be an appropriate alternate destination if the flight were 

unable to land at OASD. 

According to the program site manager, he was not aware if route planning was performed 

for the mission. The accepted visual flight rules (VFR) flight plan contained destination 

information but did not indicate the specific route of the flight. The program site manager stated 

he assumed the crews followed certain typical routes between destinations; the pilots were to fly the 

routes “GPS [global positioning system] direct” while maintaining flight in VMC and clearance 

from terrain. 

According to OAIX air traffic control transcripts, during initial radio contact with the 

ground controller, the crew announced an intended flight altitude of 10,000 feet mean sea level 

(msl) and a departure heading to the south; this departure heading was consistent with the operator’s 

typical route from OAIX to OAFR, which involved a departure and flight to the south for 

approximately 32 nautical miles (nm) to avoid the mountains west of OAIX, then a turn to the west 

direct to OAFR. 

The crew taxied the airplane for takeoff but then stopped it briefly on the taxiway and 

boarded an additional passenger.6

 The controller then cleared the flight for takeoff from runway 3, 

and the flight departed. At 0738, the OAIX controller instructed the crew to contact the departure 

controller, and the crew acknowledged. There was no record of radio communication between the 

flight crew and the departure controller, and no further known radio communication was received 

from the flight. 

A review of ground-based radar data revealed the airplane did not depart on the southerly 

heading but, instead, departed to the northwest. Radar contact was lost approximately 9.5 nm 

northwest of OAIX, consistent with the normal expected limit of radar coverage for the area. The 

last recorded radar position showed the flight on a westerly heading at an approximate altitude of 

10,000 feet msl; the position and heading were consistent with the flight entering the Bamiyan 

Valley (see figure 1). 

 

6

 According to the operator, there was no time limit restriction for loading passengers. As the accident airplane 

was taxied for takeoff, military personnel arrived and requested to board an additional passenger. The program site 

manager was able to flag down the flight crewmembers, and they stopped the airplane, so that the passenger could 

board. 
3

NTSB/AAB-06/07 

Figure 1. Map of the expected route, the last known radar position of the flight, and the 

accident site. 

The cockpit voice recorder (CVR) recording began about 0748:37.7

 The flight was 

airborne, and the first officer stated, “cruise check is complete.” Initial conversation indicated 

that the crew had never flown the selected route to OAFR and the mechanic8 noted that the 

valley they had chosen to fly through was not the direct route to OAFR. At 0753:28, the captain 

stated, “we’ll just have to see where this leads.” The CVR then recorded the captain, the first 

officer, and the mechanic discussing a topographical map, outside visual references, their current 

position coordinates (obtained from a GPS as they navigated), and their route over the mountains 

to OAFR. At 0756:12, the captain stated, “well normally we’d have time to on a short day like 

this we’d have time to play a little bit do some explorin’ but with those winds comin’ up I want 

to [expletive] get there as fast as we can.” At 0800:12, the captain stated, “with this good 

visibility ... it’s as easy as pie. you run into somethin’ big you just parallel it until you find a way 

thru [sic]. ... this is the first good visibility day I’ve had in the Casa. It’s not just good it’s 

outstanding.” 

An unidentified passenger asked about the route of flight at 0802:25, and the mechanic 

stated, “I don’t know what we’re gunna see, we don’t normally go this route.”9

 The captain 

 

7

 The times reported in the CVR transcript were measured using an elapsed time reference that associated the 

estimated accident time of 0820:00 with the end of the recording. 

8

 According to the operating specifications for the CASA 212 airplane, a mechanic is not a required 

crewmember. During the accident flight, the mechanic-certificated passenger was seated in the cockpit jumpseat. 

9

 According to the program site manager, the mechanic had flown 13 times between November 9 and 24, 2004. 
4

NTSB/AAB-06/07 

stated, “all we want is to avoid seeing rock at twelve o’clock.” At 0803:21, the first officer 

stated, “yeah you’re an x-wing fighter star wars man,” and the captain replied, “you’re 

[expletive] right. this is fun.” 

At 0803:34, the captain stated, “okay it’s about time we’re gunna start climbin’ ... we’re 

comin’ up to a box up here. ... yeah I think this valley might peter out right up here.” The first 

officer and the captain then discussed some of their previous mountain flying experiences. At 

0812:45, the captain stated, “I swear to god they wouldn’t pay me if they knew how much fun 

this was,” and the first officer replied, “yeah, yeah, this is what we do flyin’ jumpers ... we 

always do this. as low as we can get,” and the captain stated, “yeah that’s the way I use to do it.” 

At 0813:06, the captain added, “it takes an extraordinary day that you can actually get down in 

... and do some [expletive] like this.” 

At 0815:47, the first officer stated that the ridgeline off to their left had a minimum 

elevation of approximately 14,000 feet msl. The captain replied that he wanted to look for a 

notch to fly through. At 0818:26, the first officer stated, “boy it’s a good thing we’re not too 

heavy today I guess,” and the captain replied, “yeah oh I wouldn’t have done this if we were at 

gross. we can always turn around up in here.” At 0819:04, the mechanic asked, “okay you guys 

are gunna make this right?” The captain replied, “yeah h h [sic] I’m hopin’.” 

About 10 seconds later, the cockpit area microphone (CAM) recorded a sound similar to 

a stall warning tone single beep, and the mechanic immediately asked if there was a way out. At 

0819:16, the captain stated they could execute a 180o turnaround, and he instructed the first 

officer to “drop a quarter flaps.” At 0819:25, the first officer stated, “yeah, let’s turn around,” 

and the captain again requested, “drop a quarter flaps.” The mechanic then stated, “You need to 

ah make a decision.” At 0819:44, the CAM recorded a sound similar to a stall warning that 

continued to the end of the recording. The mechanic stated, “call off his airspeed for him,” and 

the first officer stated, “you got ninety five.” Eight seconds after the first officer’s statement, the 

recording ended. 

The accident site was approximately 80 nm west of OAIX and approximately 25 nm north 

of the operator’s typical route between OAIX and OAFR. The operator was notified by military 

personnel, about 1415, that the airplane had never arrived at OAFR. Search and rescue operations 

were initiated by the military about 1540, and the wreckage was located on November 28, 2004, 

about 0815. First responders who arrived at the accident site on November 30, 2004, reported 

evidence that one passenger had exited and re-entered the wreckage before he died (see Survival 

Aspects section). 

PERSONNEL INFORMATION 

The Captain 

The captain, age 37, held an airline transport pilot certificate with a rating for airplane 

multi-engine land and type ratings for “CA-212,” “CE-500,” “EMB-110,” and “SA-227” 
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NTSB/AAB-06/07 

airplanes.10 He also held commercial privileges for airplane single-engine land and airplane 

single-engine sea. His most recent Federal Aviation Administration (FAA) first-class airman 

medical certificate was dated October 1, 2004, with the limitation, “must wear corrective lenses.” 

The captain was hired by Presidential Airways on October 1, 2004. According to his 

résumé, the captain reported 5,720 total flight hours, which included 4,930 hours pilot-incommand (PIC) with 685 hours PIC in CASA 212 airplanes. According to an insurance 

application dated September 23, 2004, the captain reported 865 hours in CASA 212 airplanes. The 

director of operations of Presidential Airways reported that, during the captain’s employment 

interview, he stated he had “harsh environment” operating experience and had flown extensively 

throughout the northwestern United States and Alaska. The director of operations stated he 

verified this information with the two previous employers listed on the captain’s résumé. 

The captain began company indoctrination training with six other pilots, including the 

first officer, on October 1, 2004. He completed the indoctrination training on October 5, 2004, 

and began aircraft-specific training in CASA 212 airplanes, which he completed on 

October 9, 2004. On November 2, 2004, the captain passed an Airman Competency/Proficiency 

Check in a CASA 212 airplane in accordance with 14 CFR 135.293, “Initial and recurrent pilot 

testing requirements,” paragraphs (a) and (b); 14 CFR 135.297, “Pilot in command: Instrument 

proficiency check requirements”; and 14 CFR 135.299, “Pilot in command: Line check: Routes 

and airports.” 

The captain arrived in Afghanistan on November 14, 2004, and the next day he flew a 

6.3-hour theater-indoctrination flight with a company pilot who had experience with flying in 

Afghanistan. The flight included stops at OAIX; OAKN; Herat, Afghanistan (OAHR); and 

OASD. Records provided by the operator indicated the captain flew six subsequent missions in 

Afghanistan with, at least, one flight into OAFR. The captain accumulated a total of 32.3 hours 

in Afghanistan, which included 23.5 hours in CASA 212 airplanes. According to the operator, in 

the 90 and 30 days prior to the accident, the captain had accumulated 87.8 and 65.9 total flight 

hours, respectively. 

According to Presidential Airways’ program site manager, the captain’s last flight prior 

to the accident flight ended at 1130 on November 24, 2004. Four company pilots who lived in 

the same quarters with the captain reported that, in the 72 hours before the accident, the captain 

appeared well rested, had a good attitude, and ate regular meals. The program site manager 

estimated the captain smoked about two cigarettes per day. Two company pilots stated that, on 

the morning of the accident, the captain told them he had a sore or scratchy throat, and he 

thought he might be coming down with a cold. Both pilots stated they offered to fly for the 

captain, but the captain declined. 

 

10 These type-rating designators refer to certain CASA 212, Cessna Citation, Embraer 110, and 

Swearingen/Fairchild Metro series airplanes. 
6

NTSB/AAB-06/07 

A review of FAA airman records revealed that, on February 10, 1997, the captain was 

issued a notice of disapproval of application for an airline transport pilot certificate. He 

subsequently completed the requirements and was issued an airline transport pilot certificate on 

March 7, 1997. 

A review of Presidential Airways’ records revealed the captain reported he had never 

been convicted of reckless driving or of driving a motor vehicle under the influence, and his 

driver’s license had never been suspended or revoked. 

The First Officer 

The first officer, age 35, held an airline transport pilot certificate with a rating for airplane 

multi-engine land and commercial privileges for airplane single-engine land. His most recent FAA 

first-class airman medical certificate was dated January 28, 2004, with no waivers or limitations. 

The first officer was hired by Presidential Airways on October 1, 2004. According to his 

résumé, the first officer reported 2,228 total flight hours, which included 1,248 hours in multiengine airplanes. According to an insurance application, dated September 23, 2004, the first officer 

reported 917 hours PIC and 420 hours in CASA 212 airplanes. 

The first officer began company indoctrination training with six other pilots on 

October 1, 2004. He completed the indoctrination training on October 5, 2004, and began aircraftspecific training in CASA 212 airplanes, which he completed on October 9, 2004. On 

October 10, 2004, the first officer and another captain ferried a CASA 212 airplane from Alaska to 

Florida. On October 13, 2004, the first officer passed an Airman Competency/Proficiency Check 

in a CASA 212 airplane, in accordance with 14 CFR 135.293, “Initial and recurrent pilot testing 

requirements,” paragraphs (a) and (b), and 14 CFR 135.299, “Pilot in command: Line checks: 

Routes and airports.” 

The first officer arrived in Afghanistan on November 14, 2004, and, the next day, he flew 

a 4.8-hour theater-indoctrination flight with a captain who was experienced flying in 

Afghanistan. The flight included stops at OAIX; Salam, Afghanistan; and Jalalabad, 

Afghanistan. Records provided by the operator indicated the first officer flew five subsequent 

missions in Afghanistan with, at least, one flight into OAFR. The first officer accumulated a total 

of 29.6 hours in Afghanistan, which included 23.4 hours in CASA 212 airplanes. According to 

the operator, in the 90 and 30 days prior to the accident, the first officer had accumulated a total 

of 67 and 65.2 flight hours, respectively. 

According to the operator’s program site manager, the first officer’s last flight prior to the 

accident flight ended at 1130 on November 24, 2004. Four company pilots who lived in the same 

quarters with the first officer reported that, in the 72 hours before the accident, the first officer 

appeared well rested, had a good attitude, and ate regular meals. 
7

NTSB/AAB-06/07 

A company captain stated he had flown with the first officer during the previous three 

summers on firefighting support flights to drop smokejumpers and para-cargo11 to fight 

wildfires. He described the first officer as a knowledgeable and skilled pilot who was 

experienced with mountain flying and low-altitude missions. 

A review of FAA airman records revealed on July 9, 1991, the first officer was issued a 

notice of disapproval of application for a private pilot certificate. He subsequently completed the 

requirements and was issued a private pilot certificate on July 18, 1991. He was issued a notice of 

disapproval of application for a commercial pilot certificate on September 12, 1995. He 

subsequently completed the requirements and was issued a commercial pilot certificate on 

September 13, 1995. On October 16, 2002, he was issued a notice of disapproval of application for 

an airline transport pilot certificate. He was issued a second disapproval on October 21, 2002. He 

subsequently completed the requirements and was issued an airline transport pilot certificate on 

October 22, 2002. 

A review of Presidential Airways’ records revealed the first officer reported he had never 

been convicted of reckless driving or of driving a motor vehicle under the influence, and his 

driver’s license had never been suspended or revoked. 

AIRCRAFT INFORMATION 

The CASA 212 was an unpressurized, high-wing airplane with fixed landing gear, a rear 

ramp-type cargo door, and a maximum gross weight of 16,976 pounds (lbs). It was configured 

with nine seats. The airplane was powered by two Garrett TPE331-10R-511C, 900-shafthorsepower engines, each equipped with a Hartzell constant-speed, four-blade propeller with fullfeathering and reverse-pitch capabilities. The instrument panel was equipped with an Apollo 

GX-50 GPS. 

The cockpit was equipped with quick-donning oxygen masks for the captain and the first 

officer. The passenger oxygen masks and equipment were carried in a case and could be plugged 

into a console in the passenger area when their use was required. 

The airplane’s emergency locator transmitter (ELT) was an Artex model 110-4, which 

was designed to transmit a 121.5-megahertz (MHz) signal automatically when subjected to 

certain forces, such as those sustained during an impact. 

According to weight and balance calculations, the airplane weighed approximately 

15,664 lbs at takeoff and had a predicted landing weight of 13,714 lbs. The center of gravity (CG) at 

takeoff was calculated as 19.1 percent of mean aerodynamic chord (MAC), and the predicted 

 

11 Smokejumpers are airborne firefighters who parachute from airplanes to access wildfires in remote areas, and 

they are often supported by para-cargo drops of personal gear, food, water, and equipment. 
8

NTSB/AAB-06/07 

landing CG was 17.5 percent of MAC. According to the airplane flight manual (AFM), the 

airplane’s maximum permitted takeoff weight was 16,976 lbs, the forward CG limit for the 

calculated takeoff weight was about 16 percent of MAC, and the aft limit was about 30 percent of 

MAC. On the basis of these data, the airplane would have remained within operational limits during 

the entire accident flight. 

The stall speed of the airplane is affected by flap configuration and wing bank angle. As the 

airplane’s flap angle increases (that is, as flaps are lowered), stall speed decreases. As the airplane’s 

wing bank angle increases (to turn in level flight), stall speed increases. Based on AFM performance 

charts, the approximate stall speeds for the airplane, in knots (kts) of calibrated airspeed in various 

bank angle and flap configurations, are shown in figure 2. 

Figure 2. Approximate stall speeds for various bank angles and flap settings. 

According to the AFM’s “Balked Landing Rate of Climb - Two Engine Operation” chart, at 

14,000-feet pressure altitude, -8o Celsius, and an aircraft weight of 15,000 lbs, the climb rate would 

be about 690 feet per minute (fpm) with full flaps, takeoff power, and an airspeed of 83 kts. 

A review of maintenance records indicated that, at the time the airplane departed on the 

accident flight, it had accumulated 21,489.6 total hours. The No. 1 engine had accumulated 

11,087.3 hours since new and 363.6 hours since overhaul, and the No. 2 engine had accumulated 
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NTSB/AAB-06/07 

7,327.1 hours since new and 908.3 hours since overhaul. The airplane received its 1A and 2A 

inspections12, in accordance with the manufacturer’s guidelines, on November 25, 2004, and had 

accumulated 4.2 hours since the inspections. 

METEOROLOGICAL INFORMATION 

A weather observation taken about 0725 at OAIX, elevation 4,895 feet, recorded wind 

variable at 4 kts, unrestricted visibility, few clouds at 8,000 feet and 20,000 feet, temperature 39o 

Fahrenheit, dew point 28o Fahrenheit, and altimeter setting 30.35 inches of mercury. 

A weather forecast briefing prepared by the military at 0600 for an area that included the 

flight route predicted winds aloft from 240o at 20 kts, at 9,000 feet and 10,000 feet. The forecast 

predicted no visibility restrictions, thunderstorms, turbulence, icing, or precipitation aloft. Surface 

conditions at OASD, elevation 3,773 feet, from 1100 to 1200, were predicted to include winds from 

180o at 15 kts gusting to 25 kts and 3 statute miles visibility in blowing dust. 

Another Presidential Airways crew departed OAIX in a CASA 212 airplane about the same 

time as the accident flight, but their flight was en route to a different destination, OAHR. The 

typical route to that crew’s destination did include flight along the Bamiyan Valley, and the captain 

of that flight stated he flew within about 5 nm of the accident site. He stated that he flew at 

12,500 feet msl and observed the wind was from the southwest at 5 to 10 kts. He stated that he 

observed a scattered to broken cloud layer at 13,000 feet msl and that the cloud layer had a 

maximum thickness of 500 feet but was predominantly about 200 feet thick with cloud caps just 

above the individual mountain peaks. He estimated that there was a minimum of 10 miles of 

visibility in haze. 

FLIGHT RECORDERS 

The airplane’s Fairchild model 100A CVR was examined at the National Transportation 

Safety Board, Vehicle Recorders Division, Washington, D.C. The exterior of the CVR was 

damaged, but the tape inside sustained little damage. The CVR recording consisted of four 

channels of good quality13 audio information. One channel captured the audio from the captain’s 

panel, another captured the audio from the first officer’s panel, and a third captured the audio 

from the CAM; the fourth CVR channel was unused. The CVR captured the last 32 minutes of 

the flight, and the recording captured no radio communications between the flight crew and any 

 

12 The 1A and 2A inspections are specified by the manufacturer and are performed at 100-hour and 200-hour 

intervals, respectively. 

13 The Safety Board uses the following categories to classify the levels of the CVR recording quality: excellent, 

good, fair, poor, and unusable. A good quality recording is one in which most of the crew conversations could be 

accurately and easily understood. The transcript that was developed may indicate one to two words that were not 

intelligible. Any loss in the transcript can be attributed to simultaneous cockpit/radio transmissions that obscure each 

other. 
10

NTSB/AAB-06/07 

air traffic control facilities. The review of voice recordings from the captain, the first officer, and 

the mechanic revealed no evidence of sounds consistent with oxygen mask use. 

The airplane was not equipped, and was not required to be equipped, with a flight data 

recorder.14

WRECKAGE AND IMPACT INFORMATION 

The wreckage was at an elevation of approximately 14,650 msl in a box canyon that was 

bounded on the east and west by 15,000-foot ridgelines and terminated at a 16,580-foot peak to 

the south. The northern end of the box canyon opened to the Bamiyan Valley, where the floor of 

the canyon was approximately 11,000 feet msl; the floor of the box canyon rose from north to 

south to its terminus. The terrain was rocky, snow-covered, and void of trees and vegetation. 

The Safety Board’s accident investigation team did not travel to the accident site. The first 

military recovery team to access the site arrived on board a Boeing CH-47 helicopter, and the 

recovery team estimated that about 20 inches of snow had fallen since the accident 3 days earlier. 

The CH-47 was hovered over the site for about 10 minutes in order to use its rotor wash to blow 

away the snow. Review of photographs and information provided by the military showed the 

wreckage was located on the northern face of an area of rising terrain. According to military first 

responders, the airplane was on its left side at the northeast end of a wreckage and cargo debris path 

that extended approximately 450 feet. The responders reported that the rear cargo ramp was 

separated and on the ground adjacent to the empennage, the right wing and right engine were 

separated, and the left wing was crushed under the fuselage. Wing flap configuration was not 

determined. The CVR was the only wreckage component recovered for examination. 

The first responders reported that they observed no evidence that the captain or the first 

officer had used their oxygen masks and that the oxygen equipment for the passengers was found in 

an unopened case. 

MEDICAL AND PATHOLOGICAL INFORMATION 

Toxicological examinations of specimens from the captain and the first officer were 

performed by the Armed Forces Institute of Pathology, Washington, D.C. No evidence of 

alcohol or performance-impairing drugs was found. 

The Office of the Armed Forces Medical Examiner, Dover Air Force Base Port 

Mortuary, Dover, Delaware, performed autopsies on all six occupants of the airplane on 

 

14 According to 14 CFR 135.152, an approved flight recorder is required for a multiengine, turbine-powered 

airplane or rotorcraft that has a passenger seating configuration (excluding any required crewmember seat) of 10 to 

19 seats and that was brought onto the U.S. register (or was registered outside the United States and added to the 

operator’s U.S. operations specifications) after October 11, 1991. 
11

NTSB/AAB-06/07 

December 3, 2004. The autopsy reports stated the cause of death for the captain, the first officer, 

the mechanic-certificated passenger, and two of the active-duty military passengers was “blunt 

force injuries.” 

The autopsy report for the third active-duty military passenger stated the cause of death 

was “blunt force injuries of the torso complicated by hypoxia and hypothermia.” The Safety 

Board reviewed the autopsy findings regarding the passenger’s internal injuries and examined a 

photograph of a specific internal injury.15 

SURVIVAL ASPECTS 

Passenger with Survivable Injuries 

Military first responders who arrived at the accident site observed a body, later identified 

as the active-duty military passenger who died of injuries complicated by hypoxia and 

hypothermia, lying prone inside the rear cargo area of the wreckage. The body was oriented with 

the head toward the front of fuselage, and the clothing consisted of pants and shoes. In close 

proximity to the body were an unrolled sleeping bag, a cigarette butt, and a half-empty water 

bladder from a Camelbak hydration system. An open box of Meals Ready-to-Eat was also inside 

the fuselage, but responders could not determine if it had been opened before or after the 

accident. 

Outside the wreckage, an empty cigarette package was observed on the ground near the 

fuselage, and two frozen urine stains were observed in the snow, one near the front of the 

fuselage and one near the rear cargo ramp. A metal ladder was leaning against the fuselage in 

such a way that, according to first responders, it appeared to have been deliberately positioned to 

enable a person to climb on top of the wreckage. First responders also reported that a wooden 

pallet on top of the rear cargo ramp appeared to have been placed there. An opened Swiss Army 

daypack was found on the ground near the fuselage, and underneath it were maps and a pilot’s 

checklist. 

Notification of the Overdue Airplane 

According to the operator’s program site manager at OAIX, the airplane’s estimated time of 

arrival at OAFR was 0955, and it was due back at OAIX about 1345. Military personnel notified the 

program site manager about 1415 that the airplane had never arrived at OAFR, which was about 

30 minutes after its expected return time at OAIX. 

 

15 The autopsy report stated, “Hemoperitoneum, 1100 mL of blood; right side retro-peritoneum hemorrhage 

extending from the level of the 12th thoracic vertebrae to the pelvis (12 x 6 x 3 inches); laceration of the mesentery 

of the transverse colon and portion of the small bowel with associated ischemic bowel (10 inches in greatest 

length).” The Safety Board examined a photograph of the ischemic bowel. According to the Armed Forces medical 

examiner, 140 milliliters (mL) of urine was found in the passenger’s bladder. 
12

NTSB/AAB-06/07 

According to the DoD contract, the flight crews were required to report their arrivals at 

remote locations to the military Air Mobility Division (AMD),16 which required the arrival 

information for its own purposes; AMD was not involved in tracking flights for the operator. 

According to Presidential Airways pilots interviewed after the accident, the operator provided 

each flight crew an Iridium satellite telephone17 to report their flight’s arrival to AMD upon 

landing. One pilot stated he tried to use the satellite telephone the first month he was in 

Afghanistan but stated, “less than half the time, it would work properly. Sometimes I would fly 

my entire route and then call AMD when I landed back at [OAIX].” Another pilot stated he 

sometimes had to make five or six attempts with the satellite telephone before getting through to 

AMD, and, because of the short on-ground times, he did not have time to make repeated calls. 

Communications capability was limited at the remote locations in Afghanistan. 

The military air movement personnel at OAFR stated it was not unusual for inbound 

flights to be delayed, diverted, or canceled. Although military personnel at some remote 

locations had some communications capabilities, they stated they were not tasked to report 

aircraft arrival or departure information to the operator for the purpose of flight tracking and that 

they were unaware of any overdue aircraft notification procedures for Presidential Airways 

flights. The director of operations stated that the military would relay arrival information to the 

operations center when flight crews were unable to communicate directly. 

A member of the military quality assurance personnel (QAP) who oversaw the Presidential 

Airways contract stated he was notified, at 1330, that passengers at OAFR had been waiting for the 

airplane. He stated he went to the military command post at OAIX and began calling other airfields 

to look for the airplane. When military personnel notified the program site manager, at 1415, that 

the airplane had never arrived at OAFR, the program site manager also went to the military 

command post to initiate calls to try to find the flight. 

After calls to several possible landing sites failed to locate the airplane, military officials 

reported the missing airplane to their higher commands, about 1430, and, about 1515, the Joint 

Search and Rescue Center (JSRC) was notified. According to the operator and a JSRC timeline 

provided by the military, search and rescue aircraft were placed on alert by 1540 and were airborne 

within about 30 minutes. 

Search and Rescue 

The operator informed military search and rescue personnel that a typical flight between 

OAIX and OAFR would depart to the south for approximately 32 nm, and then proceed west 

directly to OAFR, and that the flight crew had planned to divert to OAKN if they were unable to 

land at OASD. Military search and rescue personnel were initially dispatched to search the area 

 

16 AMD was located at Al Udeid Air Base, Qatar, which was about 730 nm southwest of OAFR. 

17 According to a military Joint Search and Rescue Center timeline, the operator did not have the phone number 

to the accident airplane’s satellite telephone readily available after the accident. 
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along the flight’s alternate destination and then the area south of OAIX, based on the operator’s 

assumption that the flight had followed the typical route. Initial 121.5-MHz signals were detected18, 

about 1730, but a search revealed the signals were not associated with the airplane’s ELT. Other 

false alerts were detected, investigated, and ruled out throughout the evening. 

According to the OAIX military radar chief controller, the military’s air traffic manager site 

leader was the only person who requested radar data for the last known position of the flight from 

the OAIX Radar Approach Control (RAPCON); the air traffic manager site leader stated he made 

this request “sometime after sunset.”19 A command post controller at OAIX stated that he had twice 

requested the radar data for the accident flight from OAIX RAPCON and that he was informed that 

OAIX RAPCON could not pull the tapes and that the information was hard to get to. According to 

the OAIX command post controller, he subsequently contacted the OAIX tower20 and requested the 

radar data for the airplane’s departure, and a Presidential Airways representative and military 

personnel went to the tower to review the data. 

According to the JSRC timeline provided by the military, the radar information was 

provided to search and rescue personnel about 2100, and search aircraft subsequently began 

searching the areas north and west of OAIX, based on the flight’s last known position. 

A 121.5-MHz signal was detected in the search area northwest of OAIX about 0500 on 

November 28, 2004, and search aircraft located the wreckage about 0815. According to the military, 

weather did not significantly affect search and rescue efforts on the day of the accident. However, 

by the time the wreckage was identified, adverse weather had moved into the area. Varying degrees 

of turbulence, clouds, icing, poor visibility, and winds of 40 to 60 kts prevented rescue personnel 

from reaching the site until 0630 on November 30, 2004. 

 

18 The signals were likely detected by military resources. According to the International Civil Aviation 

Organization, Afghanistan was not a participant in the international civilian search and rescue system known by the 

acronym COSPAS-SARSAT (Cosmicheskaya Sistyema Poiska Avariynich Sudov [translation: Space System for the 

Search of Vessels in Distress] – Search and Rescue Satellite-Aided Tracking). The COSPAS-SARSAT system 

utilizes satellite and ground equipment to detect and locate the signals from 121.5-MHz and 406-MHz ELTs, and it 

forwards the information to the search and rescue authorities of participating countries and organizations to expedite 

identification of crash locations. COSPAS-SARSAT participants include the four parties to the COSPAS-SARSAT 

International Programme Agreement (Canada, France, Russia, and the United States), 24 ground segment providers, 

nine user states and two organizations, as follows: Algeria, Argentina, Australia, Brazil, Chile, People’s Republic of 

China, Denmark, Germany, Greece, India, Indonesia, Italy, Japan, Republic of Korea, Madagascar, The 

Netherlands, New Zealand, Nigeria, Norway, Pakistan, Peru, Poland, Saudi Arabia, Singapore, South Africa, Spain, 

Sweden, Switzerland, Thailand, Tunisia, Turkey, United Kingdom, Vietnam, the International Telecommunication 

Development Corporation, and the Marine Department of Hong Kong, China. 

19 The OAIX military radar chief controller stated that he contacted each of the personnel assigned to OAIX 

RAPCON duties to determine who requested the radar information from them and that they reported only the air traffic 

manager site leader contacted them. 

20 During this call, the OAIX command post controller reached the air traffic manager site leader, whom OAIX 

RAPCON personnel confirmed contacted them to request the radar information. 
14

NTSB/AAB-06/07 

ORGANIZATION AND MANAGEMENT INFORMATION 

Presidential Airways held a Part 135 operating certificate, under which it operated seven 

CASA 212 airplanes, one Fairchild Metroliner SA-227 airplane, and three McDonnell Douglas 

MD-530 helicopters. According to the director of operations, once Presidential Airways was 

awarded the AMC contract to provide services within Afghanistan, Uzbekistan, and Pakistan,21

company personnel immediately visited the military’s requested service sites and began briefings 

with the local military command on how the operations would be conducted. Due to safety 

concerns and aircraft performance limitations, the operator declined to service some of the 

military’s requested sites. 

According to an FAA air safety inspector, during the year before the accident, the FAA’s 

oversight of Presidential Airways included more than 100 visits to the operator’s facility in 

Florida. During those visits, the FAA identified minor discrepancies, which the operator 

subsequently corrected, and no violations were issued. The FAA inspector stated that he was not 

aware of any FAA oversight of Presidential Airways’ operations in Afghanistan. 

In addition to the FAA requirements, Presidential Airways, under contract to AMC, was 

required to adhere to the provisions of 32 CFR Part 861 regarding flight crew training, 

qualifications, and proficiency. Title 32 CFR Part 861 also requires that the DoD approve and 

monitor contract operators for compliance with contract provisions, including safety provisions. 

Such monitoring should entail initial and recurring on-site safety surveys and evaluation. These 

evaluations of Presidential Airways would be performed by the DoD QAP personnel in 

Afghanistan who were tasked to ensure that the operator complied with the contract.22 According 

to the regulation, the DoD oversight requirements are intended to “complement rather than 

replace the [FAA] criteria applicable to the carrier” and pertain to the “enhanced level of service 

required” for DoD operations.23 According to 32 CFR 861.4(c)(3), a consideration in the 

evaluation process included that an “air taxi operator is expected to demonstrate some type of 

effective flight following capability.” 

Flight Dispatch and Locating 

Presidential Airways dispatched the flights requested by the military from its operations 

center at OAIX. According to the program site manager, all flights were flown VFR, and the 

flight crews would file a company flight plan with the operator that contained the mission’s 

intended destinations. The director of operations stated that the “normal procedure” for flight 

 

21 The contract was awarded on September 20, 2004, and Presidential Airways’ first airplane arrived in 

Afghanistan 5 days later. Two CASA 212 airplanes, including the accident airplane, and one SA-227 airplane were 

used for the AMC contract. 

22 The QAP personnel stated that they coordinated with the operator in scheduling and rescheduling missions, 

manifested passengers and cargo, and met with every departure to ensure the airplanes were loaded with the correct 

cargo and mail. 

23 The requirements are outlined in 32 CFR 861.4(a) and (e). 
15

NTSB/AAB-06/07 

crews was to contact the operations center upon landing at remote locations, if able. The director 

of operations stated that, if the flight crews were unable to establish contact because of 

communications problems, the flight crews could log their remote site arrival times upon their 

return to OAIX at the completion of the entire mission. According to one pilot, an airplane was 

not considered overdue until it exceeded its estimated return time at OAIX. 

Presidential Airways pilots stated their routes were flown using GPS-direct navigation. 

They stated that, although the flights did not use standard routes between destinations, they 

usually flew within 5 to 10 nm of the centerline of typically flown routes, and they would not 

have expected the accident flight to have been flying as far north as the accident location. The 

program site manager stated that terrain, weather, and a desire to avoid establishing a flight 

pattern in an environment with hostile ground forces were some reasons the flight crews varied 

the specific ground track of each flight. He also stated that, due to military helicopter operations, 

the flight altitude of the company’s airplanes was required to be no lower than 1,500 feet above 

the level of the average lowest terrain. 

Flight Crew Training Program 

According to the director of operations, from October 1, 2004, to November 14, 2004, the 

captain and the first officer had each received approximately 130 hours of ground instruction, 

including 60 hours of systems training, 50 hours of indoctrination training, 2.5 hours of flight 

training in CASA 212 airplanes, and crew resource management (CRM) training. The CRM 

training consisted of a 30-minute instructional video and a 1.5-hour discussion.24 

According to the director of operations, the captain and the first officer were not provided 

training in mountain flying because the training was not a requirement under Part 135, and each had 

“extensive” mountain-flying backgrounds. The training program did include emphasis on pilot and 

passenger regulations specific to Part 135 operations, which included guidelines on pilot and 

passenger oxygen use. According to other Presidential Airways pilots interviewed about their own 

use of oxygen, one pilot stated he would use oxygen only occasionally during flights above 

13,500 feet msl, and another pilot incorrectly stated the altitude requirements for oxygen use.25

 

24 FAA Advisory Circular (AC) 120-51E defines CRM as the “effective use of all available resources: human 

resources, hardware, and information.” According to AC 120-51E, among the goals of CRM training is to address the 

challenges of optimizing crew problem-solving and decision-making skills, and the crew’s ability to maintain situational 

awareness. Since 1980, the Safety Board has issued numerous recommendations to the FAA regarding improved CRM 

training requirements for Part 135 operators. The Board’s most recent recommendation on this subject, Safety 

Recommendation A-03-52, was issued on December 2, 2003, and asked the FAA to “require that ... Part 135 on-demand 

charter operators that conduct dual-pilot operations establish and implement a Federal Aviation Administration-approved 

crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and 

O.” Following the November 28, 2004, Canadair, Ltd., CL-600-2A12 accident in Montrose, Colorado, the Board noted 

that the FAA’s action on this issue is overdue, and, on August 4, 2006, the Board reclassified Safety 

Recommendation A-03-52 “Open—Unacceptable Response” and reiterated the recommendation. The recommendation 

letter is available on the Safety Board’s Web site at <http://www.ntsb.gov>. 

25The pilot stated that it was his understanding that, if the airplane was above 12,500 feet for more than 

30 minutes or if it was above 14,000 feet, he had to use oxygen. According to Federal regulations, pilots of 
16

NTSB/AAB-06/07 

According to the program site manager, there was no formal Afghanistan theater-orientation 

program for the pilots. The company’s standard practice was to pair new captains with another 

captain or a theater-experienced first officer for one or two missions; new first officers were paired 

with theater-experienced captains. The program site manager stated the accident captain and first 

officer were paired for mission-planning reasons because they were the only CASA 212 crew on 

site who could also fly Presidential Airways’ SA-227 airplane. 

ADDITIONAL INFORMATION 

Flight-locating Requirements 

According to 14 CFR 135.79, “Flight locating requirements”: 

(a) Each certificate holder must have procedures established for locating each 

flight, for which an FAA flight plan is not filed, that— 

(1) Provide the certificate holder with at least the information required to 

be included in a VFR flight plan; 

(2) Provide for timely notification of an FAA facility or search and rescue 

facility, if an aircraft is overdue or missing; and 

(3) Provide the certificate holder with the location, date, and estimated 

time for reestablishing radio or telephone communications, if the flight 

will operate in an area where communications cannot be maintained. 

(b) Flight locating information shall be retained at the certificate holder’s 

principal place of business, or at other places designated by the certificate holder 

in the flight locating procedures, until the completion of the flight. 

(c) Each certificate holder shall furnish the representative of the Administrator 

assigned to it with a copy of its flight locating procedures and any changes or 

additions, unless those procedures are included in a manual required under this 

part. 

 

unpressurized airplanes are required to use oxygen if the airplane is above 10,000 feet msl through 12,000 msl feet 

for more than 30 minutes duration and at all times above 12,000 feet msl (see Additional Information section, 

Regulations and Guidelines). 
17

NTSB/AAB-06/07 

Oxygen-use Requirements 

According to 14 CFR 135.89, “Pilot requirements: Use of oxygen,” “Each pilot of an 

unpressurized aircraft shall use oxygen continuously when flying, (1) At altitudes above 

10,000 feet through 12,000 feet msl for that part of the flight at those altitudes that is of more 

than 30 minutes duration; and (2) Above 12,000 feet msl.” 

According to an aviation medicine textbook,26 from 10,000 to 15,000 feet, an individual 

without supplemental oxygen “exhibits few or no signs and has virtually no symptoms [of 

hypoxia].27 The ability to perform skilled tasks is impaired, ... an effect of which the subject is 

frequently unaware.” The textbook also notes that “an individual breathing air at 8,000 feet may 

take significantly longer to achieve optimum performance at novel tasks than is the case at sea 

level. For example, this degree of hypoxia has been found to double the reaction times of initial 

responses to a complex choice-reaction task as compared with the responses at sea level. The 

intensity of this effect increases with altitude and complexity of the task, markedly so, about 

12,000 feet.”28 Studies also noted research subjects exhibited mental performance impairment 

during task tests that were begun after only 5 minutes29 and 10 minutes30 of exposure to a 

simulated altitude of 8,000 feet. 

Emergency Locator Transmitter Equipment 

The airplane’s Artex ELT 110-4 was approved in accordance with Technical Standard 

Order (TSO)-C91a, and it satisfied the FAA’s equipment requirement specified in 14 CFR 

91.207, “Emergency locator transmitters.”31 Units approved under TSO-C91a operate on the 

frequency of 121.5 MHz at a power output of 0.1 Watt. According to data from the National 

Oceanic and Atmospheric Administration (NOAA),32 only about one in five 121.5-MHz alerts 

originate from actual ELT units, and actual alert signals are not discernible from many non-ELT 

sources that produce interference. Fewer than 2 in 1,000 121.5-MHz alerts are from actual 

 

26 Harding, R.M.; Gradwell, D.P. 1999. Hypoxia and Hyperventilation. In: Aviation Medicine, Third Edition. 

Butterworth Heinemann, Oxford, U.K. p. 55. 

27 According to the FAA Aeronautical Information Manual, paragraph 8-1-2, “Effects of Altitude,” hypoxia is 

“a state of oxygen deficiency in the body sufficient to impair functions of the brain and other organs.” 

28 Harding and Gradwell. 1999. p. 53. 

29 Kelman, G.R.; Crow, T.J. 1969. Impairment of mental performance at a simulated altitude of 8,000 feet. In: 

Aerospace Medicine 40 (9). pp. 981-982. 

30 Denison, D.M.; Ledwith, F.; Poulton, E.C. 1966. Complex reaction times at simulated cabin altitudes of 

5,000 feet and 8,000 feet. In: Aerospace Medicine. pp. 1010-1013. October 1966. 

31 According to 14 CFR 91.207, “Emergency locator transmitters,” a U.S.-registered civil airplane must be 

equipped with an approved automatic-type ELT. According to 14 CFR 135.25, “Aircraft requirements,” no 

certificate holder may operate an aircraft under this part, unless that aircraft “ ... meets the applicable airworthiness 

requirements of this chapter.” The chapter includes the requirements outlined in Part 91. 

32 Information obtained November 22, 2005, from the home page of NOAA National Environmental Satellite, 

Data, and Information Service (NESDIS), Comparison of the 406 MHz and 121.5 MHz Distress Beacons, <http://www.sarsat.noaa.gov>. 
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distress situations. Since 121.5-MHz units transmit signals anonymously, the only way to 

ascertain whether or not an alert is an actual distress situation is to dispatch resources to 

investigate the location. The position accuracy of 121.5-MHz units is approximately 12 to 

15 nm. 

In contrast, ELT units approved in accordance with TSO-C126 operate at a frequency of 

406 MHz at a power output of 5 Watts. According to NOAA data, all alerts originate from actual 

ELT units as digital, coded signals that are detected near-instantaneously by satellites; about 1 in 

12 alerts are from actual distress situations. The coded signals provide searchers with aircraft 

registration and point of contact information. The position accuracy of 406-MHz units is 

approximately 1 to 3 nm, and some units are enhanced with an integral GPS feature that enables 

position accuracy of less than 100 yards. 

According to 59 Federal Register (FR) 32050, published on June 21, 1994, the FAA 

stated, “Voluntary use of the 406-MHz ELTs would provide a definite enhancement over the 

minimum requirements of the Federal Aviation Regulation.33 There may be even more lifesaving benefits ... for those operations conducted over water and in remote areas.” Further, 

according to 66 FR 34913, published on July 2, 2001, the COSPAS-SARSAT program decided 

to cease the satellite processing of 121.5-MHz signals by February 2009 because those signals 

“inundate search and rescue authorities with poor accuracy and numerous false alerts, adversely 

impacting the effectiveness of lifesaving services.” COSPAS-SARSAT reported this decision 

was made, in part, in response to guidance from the International Civil Aviation Organization 

and further stated that, “although the 406-MHz beacons currently cost more, they provide search 

and rescue agencies with more reliable and complete information to do their job more efficiently 

and effectively.” 

 

33 According to 14 CFR Part 91.207, only an “approved automatic-type ELT” is required, which includes 

approved 121.5-MHz units. 
19

NTSB/AAB-06/07 

ANALYSIS 

The unpressurized airplane collided with mountainous terrain at an elevation of 

14,650 feet msl in a box canyon about 80 nm west of the departure airport in daylight visual 

meteorological conditions. The wreckage was located approximately 25 nm northwest of the 

operator’s typical route between the departure airport, OAIX, and the destination airport, OAFR. 

Prior to takeoff, the crew had announced to the air traffic control tower a departure heading to 

the south, which was consistent with the typical route, but the airplane instead turned to the 

northwest immediately after departure. 

The CVR recording, which began when the airplane was already in cruise flight, yielded 

no discussions among the crew regarding their decision to deviate from the typical route. 

However, given that the pretakeoff briefing included intelligence that there were no military 

threats expected for the route and that the airplane deviated from that route immediately after 

takeoff, the crew’s decision to deviate likely was not made on the basis of perceived ground 

threats. Further, the mechanic-certificated passenger, who, according to the CVR was assisting 

with navigation duties, was familiar with the route structures and commented, “we don’t 

normally go this route.” It is not clear when the crew decided to fly the northerly route, but it is 

clear that the crew intentionally did not follow the direct route to OAFR and continued the flight 

through the Bamiyan Valley. The captain even commented that this was the first clear day since 

he’d been in Afghanistan and that at times he was open to “play” and “do some explorin’.” 

The captain and the first officer were both experienced in mountain flying, and the CVR 

transcript of discussions between the captain and the first officer indicated they were behaving 

unprofessionally and were deliberately flying the nonstandard route low through the valley for 

“fun.” The captain commented that the visibility was outstanding and that it takes such 

extraordinary conditions to enable him to “get down in ... and do some [expletive] like this.” 

This comment, combined with his comments about having fun and that he “wouldn’t have done 

this if we were at gross,” indicates that the captain made a conscious decision to fly the airplane 

in the manner in which he was flying and that he wouldn’t have chosen to fly the airplane in such 

a manner if the airplane had been at maximum gross weight. 

The discussions among the flight crew also indicated they were aware the airplane was 

approaching the terminus of a box canyon more than 15 minutes before the airplane struck 

terrain. Prior to collision with terrain, the captain made statements that indicated he was 

uncertain the airplane could clear the terrain and that he hesitated in making a decision on 

whether to continue to climb the airplane or to turn it around. According to the airplane’s 

performance charts, at the atmospheric conditions present at the time and the altitude of the accident 

site, the accident airplane would have been able to establish a climb. However, the pilots would 

have to ensure that the climb was initiated in sufficient time to enable the airplane to clear the 

mountain ridge. In the final seconds of the flight, it was the mechanic seated in the cockpit 

jumpseat who prompted the captain to make a decision whether or not to execute an 180o 

turnaround and who prompted the first officer to call off the airspeeds for the captain to assist 

with preventing a stall. The airplane collided with the rising terrain in a direction consistent with 
20

NTSB/AAB-06/07 

an attempted 180o turnaround. The terrain was rocky, snow-covered, and void of trees and 

vegetation. 

Because of radar coverage limitations, the flight’s cruise altitude is not known, however, 

the floor of the box canyon rose from a minimum elevation of about 11,000 feet msl, and the 

airplane collided with terrain at 14,650 feet msl. The airplane was not pressurized, and neither 

the captain nor the first officer was using the airplane’s oxygen system as required by Federal 

regulations. According to studies, from 10,000 to 15,000 feet msl, a person without supplemental 

oxygen can be expected to be impaired by hypoxia, yet the person will exhibit few or no signs, 

have virtually no symptoms, and will likely be unaware of the effect. Studies also noted mental 

performance impairment in research subjects on tests beginning after only 5 minutes34 and 

10 minutes35 of exposure to a simulated altitude of 8,000 feet. In this accident, the flight crew 

was vulnerable to the effects of hypoxia because they were not using supplemental oxygen as 

required; however, there was insufficient evidence to determine the extent to which hypoxia 

affected the crew’s performance. 

The DoD contract flights were flown “GPS direct” at the pilots’ discretion. The company 

flight plans filed by each crew contained only destination information and did not define specific 

routes of flight. According to 14 CFR 135.79, “Flight locating requirements,” an operator must 

have procedures established that provide for timely notification of a search and rescue facility if 

an aircraft is overdue or missing; Presidential Airways had no such procedures for its DoD 

contract operations. According to 32 CFR 861.4(c)(3), the DoD was required to evaluate its 

contract operators; as part of the evaluation, an “air taxi operator is expected to demonstrate 

some type of effective flight following capability.” 

The Presidential Airways director of operations stated that crews were required to report 

their remote site arrival times to the operations center at OAIX. However, the operator’s 

communications capabilities were limited at some remote sites, so crews were allowed simply to 

log their remote site arrival times upon their return to OAIX, at the completion of the entire 

mission. Because of this practice, it was not unusual for the operations center not to hear from a 

flight at every arrival site. Therefore, although the accident flight never arrived at OAFR (its first 

destination) as expected at 0955, the operator was unaware the airplane was missing until about 

1415, which was when military personnel at OAFR reported that the airplane had never arrived. 

When telephone and radio searches failed to locate the airplane, air search and rescue 

operations were initiated by the military about 1540. By the time the air searches were initiated, the 

injured survivor had been stranded at the downed airplane for about 7 hours. His rescue was further 

delayed when the subsequent 5 hours of aerial searches were focused in areas where the airplane 

had not flown; military search and rescue personnel were initially dispatched to search the area 

 

34 Kelman and Crow. 1969. pp. 981-982. 

35 Denison, Ledwith, and Poulton. 1966. pp. 1010-1013. 
21

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along the flight’s alternate destination route and then the area south of OAIX, based on the 

operator’s assumption that the flight had followed the typical route. 

Military radar data of the airplane’s last known position, which showed the airplane 

actually departed to the northwest, were provided to searchers about 2100; subsequent searches 

were then focused northwest of OAIX, based on the radar-derived position. A 121.5-MHz signal 

was detected in the northwest search area about 0500 on November 28, 2004, and search aircraft 

located the wreckage about 0815. According to the military, weather did not significantly affect 

search and rescue efforts on the day of the accident. By the time the wreckage was identified, 

however, adverse weather had moved in that prevented rescue personnel from reaching the site until 

0630 on November 30, 2004. 

A review of the autopsy report for the active-duty military passenger, who initially 

survived at the accident site but died before help arrived, indicated that none of his injuries were 

immediately life threatening. One injury diagnosis, in particular, was consistent with at least 8 to 

9 hours of survival.36 Moreover, urine evidence from the accident scene and from the passenger’s 

autopsy,37 as well as medical research data regarding urine output rates38 and bladder 

capacities,39 indicate that a minimum of nearly 10 hours would have passed from the time of the 

accident to the time of his death.40 Thus, the information available to the Safety Board is 

consistent with an absolute minimum survival time of approximately 8 hours following the 

accident. If the passenger had received medical assistance within that time frame, followed by 

appropriate surgical intervention, he most likely would have survived. 

Presidential Airways was a civilian operator under contract to the DoD to provide 

transport services under Part 135 and Part 861 for U.S. military personnel and cargo. The 

operator had been providing services in Afghanistan for about 2 months, and it dispatched flights 

from its operations center at OAIX. During the year before the accident, the FAA visited 

Presidential Airways’ facility in Florida more than 100 times. During those visits, the FAA 

identified minor discrepancies, which the operator subsequently corrected, and no violations 

 

36 The autopsy report noted, “laceration of the mesentery of the transverse colon and a portion of the small 

bowel with associated ischemic bowel (10 inches in greatest length).” A photograph of that section of injured bowel 

showed that it had darkened to an almost-black color due to the loss of blood supply to the injured area. Such 

discoloration was noted in animal studies to begin after approximately 8 to 9 hours following loss of blood supply to the 

section of bowel. (Source: Marston, A. 1971. Experimental aspects of superior mesenteric artery occlusion. In: 

Vascular Disorders of the Intestine. Appleton-Century-Crofts, New York, NY. pp. 345-357.) 

37 The passenger’s bladder contained 140 mL of urine at autopsy. 

38 Based on the passenger’s extensive internal bleeding, his urine output would likely not have been much 

higher than 30 mL per hour. (Source: American College of Surgeons Committee on Trauma, Advanced Trauma Life 

Support for Doctors Student Course Manual, Chicago, 1997 p. 98.) 

39 The first urge to urinate is generally felt when the bladder contains about 150 to 250 mL of urine. (Source: 

Tanagho, E.A.; Lue, T. F. 2004. Neuropathic Bladder Disorders. In: Smith’s General Urology, Sixteenth Edition. 

Lange Medical Books, New York, NY. pp. 435-452.) 

40 This assumes that the passenger emptied his bladder immediately following the accident and voided again 

upon initially feeling the urge to do so. 
22

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were issued. Although the FAA approved that the operator could conduct Part 135 operations in 

Afghanistan, the operator did not provide, and was not required to provide, personnel who could 

directly oversee the operations there. 

Although the DoD contract stated that the company must operate in accordance with 

Part 135 specifications, evidence indicates that Presidential Airways’ operations in Afghanistan 

were not in accordance with Part 135 in areas, such as the use of flight plans, supplemental 

oxygen, and flight locating, and no FAA personnel were present in Afghanistan to ensure 

adherence to the specifications. Further, according to Federal regulations, the DoD had the 

responsibility to oversee Presidential Airways to ensure an enhanced level of service was 

provided to coincide with the DoD mission. However, no evidence was found to suggest that 

DoD personnel ensured that the operator demonstrated some type of effective flight-following 

capability or ensured any oversight. The Safety Board is concerned that the unique risks and 

oversight challenges presented by operations in remote overseas locations have not been 

adequately addressed for civilian contractors that provide air transportation services to the U.S. 

military. 

In summary, the Safety Board concludes: 

• The flight crew flew a nonstandard route into a box canyon and did not take 

remedial action in a timely manner. 

• The flight crew did not use supplemental oxygen as required by Federal 

regulations for the altitudes at which the flight was operating. 

• The operator did not provide sufficient oversight of and guidance to it its flight 

crews. 

• The operator did not ensure that operations in Afghanistan were conducted in 

compliance with Part 135 regulations. 

• The operator’s dispatch procedures were inadequate in that they did not ensure 

that specific routes of flight were defined and flown. 

• The operator did not adequately mitigate the limited communications 

capability at some remote sites. 

• The operator’s flight-locating procedures were inadequate in that they did not 

consistently track flight arrivals at each remote location in a timely manner. 

• Once the airplane was identified as missing, the coordination of the search and 

rescue effort was flawed, and radar data of the airplane’s last known position 

were not provided to searchers in a timely manner. 
23

NTSB/AAB-06/07 

• The FAA did not provide adequate oversight of the Part 135 operations in 

Afghanistan. 

• The DoD did not provide adequate oversight of the contract carrier’s 

operations in Afghanistan that was consistent with the safety provisions of the 

DoD’s contract with Presidential Airways and the regulations in 32 CFR 

Part 861. 

• If the passenger had received timely medical assistance, followed by 

appropriate surgical intervention, he most likely would have survived. 

PROBABLE CAUSE 

The captain’s inappropriate decision to fly a nonstandard route and his failure to maintain 

adequate terrain clearance, which resulted in the inflight collision with mountainous terrain. 

Factors were the operator’s failure to require its flight crews to file and to fly a defined route of 

flight, the operator’s failure to ensure that the flight crews adhered to company policies and FAA 

and DoD Federal safety regulations, and the lack of in-country oversight by the FAA and the 

DoD of the operator. Contributing to the death of one of the passengers was the operator’s lack 

of flight-locating procedures and its failure to adequately mitigate the limited communications 

capability at remote sites. 
24

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Member Hersman, Concurring: 

This accident presented a rather unique set of circumstances for the Safety Board to 

consider. We were asked to investigate a civilian accident that occurred in a theater of war while 

the operator was conducting operations on behalf of the Department of Defense. In analyzing 

the facts of this accident and in devising safety recommendations to address the problems that 

surfaced in the accident, the Safety Board has had some difficulty in determining whether 

recommendations should go to the FAA, as the Federal agency with safety oversight over 

civilian air operations, or to DoD, as the agency that had more actual control over the nature and 

conduct of this particular flight. Staff’s recommendation for a solution to this dilemma is to 

issue recommendations to both agencies and then further recommend that DoD and FAA in the 

future articulate between themselves to what extent each agency has safety oversight in similar 

circumstances. Given the large number of these types of flights, it is perplexing that DoD and 

FAA have not executed a Memorandum of Understanding to memorialize the nature of their 

relationship with regard to these flights. 

At first glance, the solution proposed by staff seems to be the best response for a third 

party Federal agency, like the NTSB, to take in this politically delicate situation. However, on a 

second look, it becomes apparent that it leaves open too many questions about control and 

responsibility and provides no real roadmap for dealing with the next atypical military 

contract/civilian air operation that ends in a crash. 

Furthermore, the proposed recommendations in this report leave open the expectation that 

FAA can and does have oversight responsibility in a war theater halfway around the world, even 

though FAA does not have any oversight personnel assigned there. Our recommendations to 

FAA would imply that the Safety Board believes that FAA should have personnel assigned to 

oversee operations in Afghanistan, Iraq, and presumably any other military or intelligence 

theater, simply because DoD or other government entities have chosen to contract flights to 

civilian operators. This is an uncomfortable position for this Board member, given the fact that 

FAA resources are already stretched thin to effectively perform their safety oversight 

responsibilities for civilian air operations based in the U.S. 

This position is even more difficult to defend given the fact that the NTSB, whose 

investigative authority also is limited to civilian air operations, did not have a presence in 

Afghanistan. In fact, the Safety Board’s policy, with which I do not disagree, is to not send its 

investigators to war theaters or other scenes of hostile military activities. In the case of this 

accident, the Safety Board’s analysis and report are based on facts and evidence gathered by 

DoD, because Safety Board investigators did not go to the scene. If this accident was the result 

of a civilian operation over which the FAA should have exercised its oversight authority, then it 

should have been considered a civilian accident in which the Safety Board should have exercised 

its investigative authority. This is not to suggest that the Safety Board should change its policy 

about deploying investigators to hostile military environments. Rather, this suggests that if the 

Safety Board did not consider the environment surrounding this accident safe enough in which to 

conduct a civilian accident investigation, it may not be appropriate to conclude that the FAA was 
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NTSB/AAB-06/07 

wrong to have delegated its civilian safety oversight functions to the DoD in the same 

environment. 

While I am signing this report as written, I continue to have reservations about the 

appropriateness of citing FAA in the probable cause for this accident when it is clear that this 

was a dangerous environment for their inspectors and clearly a military operation subject to DoD 

control. I believe that it would have been more fitting simply to address recommendations to the 

FAA so that this situation can be clarified and corrected in the future. The Safety Board, for 

example, could have recommended that FAA refuse to list countries on an operator’s Ops Specs 

if there is no established mechanism for in-country oversight comparable to the FAA’s domestic 

oversight. 

I understand and appreciate the sensitivity of this accident investigation and the difficulty 

it presented the Safety Board in concluding a probable cause and making recommendations to 

address it. On the other hand, it is not unreasonable, given DoD’s current inclination to contract 

many of its operations to civilians, that this situation will arise again. 

[Original Signed] 

Deborah A. P. Hersman