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The ATSB has released a major accident report on behalf of the Government of East Timor into the fatal accident on 31 January 2003 which resulted in six fatalities.

The ATSB found that the accident occurred when a large Russian-made Ilyushin IL-76 cargo jet aircraft crashed at Baucau, East Timor in bad weather after impacting terrain while attempting to land.

On behalf of the East Timor Government the ATSB, with the assistance of Australian Defence (DFS-ADF and DSTO) officers and the Moscow-based Commonwealth of Independent States Interstate Aviation Committee, investigated the accident.

The final investigation report was released following a briefing provided late yesterday by the ATSB and the Australian Ambassador to the Prime Minister and other members of the Timor-Leste Ministerial Council.

While it is not the object of an ATSB investigation to apportion blame or liability, the investigation found in addition to the bad weather, the aircraft crew didn't have accurate aerodrome charts and there was poor crew resource management (CRM) in the cockpit.

The aircraft descended below the lowest safe altitude for the sector and impacted terrain well short of the runway in a controlled flight into terrain (CFIT) accident which is a preventable but common cause of major accidents around the world.

Safety recommendations from the report to avoid CFIT include better use of available technology and equipment, implementing standard operating procedures, and improving collegiate crew decision-making, risk assessment and management.

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Last update 01 April 2011