Embraer EMB-120 Brasília | Bureau of Aircraft Accidents Archives

The crew was completing a local training flight at São José dos Campos Airport. While circling with one engine out, the pilot-in-command lost control of the airplane that crashed near the runway. Five occupants were killed and four others were injured.

Crash of an Embraer EMB-120RT Brasília in Bordeaux: 16 killed

Date & Time: Dec 21, 1987 at 1510 LT

Type of aircraft:

Embraer EMB-120 Brasília

Operator:

Registration:

F-GEGH

Flight Phase:

Landing (descent or approach)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Airport (less than 10 km from airport)

Schedule:

Brussels - Bordeaux

MSN:

120-033

YOM:

1986

Flight number:

AF1919

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2394

Captain / Total hours on type:

101.00

Copilot / Total flying hours:

1326

Copilot / Total hours on type:

215

Aircraft flight hours:

2505

Circumstances:

Following an uneventful flight from Brussels, the crew contacted Bordeaux Approach at 15:01 and was vectored for an ILS approach to runway 23. Visibility was poor with low clouds at 100 feet and a runway visual range (RVR) of between 650 and 350 metres. Flight 1919 crossed the KERAG beacon, the initial approach fix (IAF) at an altitude of FL144, at 15:04:40. Cloud base was still around 100 feet so the crew requested to enter a holding pattern to the south of the airport. The weather conditions slightly improved during the next few minutes and Bordeaux Approach reported a cloud base at 160 feet. Flight 1919 had not reached the holding pattern yet and the pilot decided to attempt to rejoin the ILS. At 15:06:38 the flight was cleared direct to the BD beacon and to descend down to 2000 feet. At the BD beacon, the flight was cleared for final approach and instructed to contact Bordeaux Tower. The airplane had overshot the centreline and was slightly right on the glidepath. Bordeaux Tower then instructed the flight to report over the Outer Marker, which was acknowledged by the captain. After crossing the Outer Marker, the airplane was still not properly established on the ILS. The airplane descended below the glideslope with the crew hurriedly deploying flaps and landing gear. The captain did not contact Bordeaux Tower as requested. Instead he took over control of the airplane, attempting to continue the approach. Both crew members had very little time to adapt to their new roles as the airplane was descending below the glide slope. The descent continued until the aircraft struck tree tops and crashed in the Eysines forrest, about 5 km short of runway. The aircraft was totally destroyed and all 16 occupants were killed.

Probable cause:

The accident was the direct result of poorly managed aircraft trajectory.
- The lack of vigilance with respect to altitude, by one pilot and then the other, when they were in a pilot-flying situation (PF, according to the Air Littoral Operations Manual) both when the aircraft descended out of the ILS beam through 2000 feet altitude and when it descended below 220 feet, the decision height.
- Inadequate coordination of tasks between the two pilots who formed the flight crew, neither of which had performed important tasks related to this function, such as monitoring and reporting ILS or altitude deviations, while in a nonpilot-flying situation (PNF, according to the same manual).

Final Report:

Crash of an Embraer EMB-120RT Brasília near Mantiqueira: 5 killed

Date & Time: Sep 19, 1986 at 1515 LT

Type of aircraft:

Embraer EMB-120 Brasília

Operator:

Registration:

N219AS

Flight Phase:

Flight

Flight Type:

Delivery

Survivors:

Site:

Mountains

Schedule:

São Jose dos Campos - Brasília - Manaus - Caracas - Fort Lauderdale - Atlanta

MSN:

120-019

YOM:

1986

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

Circumstances:

Brand new, the aircraft was took over by ASA crew to be delivered to Atlanta, Georgia. He was cleared by the São José Tower controller to follow the 010° radial to the SJC VOR, and cross the VOR at 5,000 feet. Some time after takeoff São José Tower instructed the flight to climb to FL280 out of 5,000 feet and intercept the 352 radial of the SJC VOR. The flight crew failed to follow the instructions and continued at an altitude of 5,000 feet. In limited visibility due to low clouds, the airplane struck the slope of a mountain located in the Mantiqueira Mountain Range. The wreckage was found 700 feet below the summit. All five occupants were killed.

Probable cause:

The following findings were reported:
- The pilots did not plan the flight properly, though there was an AIS room with the necessary sources of consultation. Maintaining altitude of 5000 feet for too long a time, subject to the minimum safe altitudes in the are area in the available publications, and the discrepancies found in the flight plan confirm this thesis.
- The pilot did not properly collated the guidelines issued by the tower and remained incompatible altitude with instructions issued by the control.
- There are strong indications that the flight proceeded under instrument flight conditions.
- There was no proper coordination between the ACC BS and TWR SJ regarding the transference and control of the air traffic nor did TWR SJ requested receipt of the messages.