Brazil

Operator:

Registration:

PT-RAZ

Flight Phase:

Flight Type:

Aerial photography

Survivors:

Site:

Schedule:

Bom Jesus da Lapa – Brasília

MSN:

820-114

YOM:

1980

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3000

Captain / Total hours on type:

2700.00

Aircraft flight hours:

2633

Circumstances:

Following an uneventful flight from Bom Jesus da Lapa, the pilot started the descent to Brasília Airport runway 29. On final approach, in a gear and flaps down configuration, the aircraft suffered an engine failure. The pilot elected to restart the engine when the aircraft deviated from the approach path to the right, lost height and struck a promontory located 61 metres from the runway threshold. Both occupants were seriously injured and the aircraft was damaged beyond repair. 23 days later, the passenger died from his injuries.

Probable cause:

No technical anomalies were found on both engines. The fuel selector was positioned on the auxiliary tanks who had sufficient fuel at the time of the accident. It was reported that the pilot elected to continue the approach on one engine, letting himself be carried away by the luck factor that he benefited in the past in other similar situations.

Final Report:

Crash of a Lockheed C-130E Hercules near Campo dos Afonsos AFB: 9 killed

Date & Time: Sep 27, 2001 at 1215 LT

Type of aircraft:

Lockheed C-130 Hercules

Operator:

Registration:

2455

Flight Phase:

Flight Type:

Military

Survivors:

Site:

Mountains

MSN:

4202

YOM:

1967

Location:

Campo dos Afonsos AFB

Rio de Janeiro

Country:

Brazil

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

While descending to Campo dos Afonsos AFB, the crew encountered poor weather conditions with limited visibility due to fog and rain falls. Too low, the four engine aircraft struck the slope of a mountain located about 15 km southeast of the airbase. All nine occupants were killed.

Crash of a Britten-Norman BN-2A-27 in Bujari

Date & Time: Sep 22, 2001 at 1207 LT

Type of aircraft:

Britten-Norman Islander

Operator:

Registration:

PT-KTQ

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Rio Branco - Rio Branco

MSN:

493

YOM:

1976

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

12000

Captain / Total hours on type:

300.00

Circumstances:

The twin engine aircraft departed Rio Branco with four passengers and one pilot on board. The goal of the flight was to carry four Japanese journalists who wanted to perform aerial views from various tribes located in the region of Santa Rosa do Purus. About 30 minutes into the flight, an oil leak occurred on the left engine that lost power. The pilot reduced his altitude and attempted an emergency landing when the aircraft crashed near Bujari, about 39 km from Rio Branco. The wreckage was found near motorway BR364 and all five occupants were slightly injured.

Probable cause:

The following findings were identified:
- It is likely that the pilot did not use the controls properly to maintain an adequate control of the airplane in a single-engine configuration while the airplane was operated within weight and balance limits,
- The left propeller retainer had been replaced by similar but not original equipment, using glue to ensure its tightness, which was non compliant with the engine manufacturer's procedures,
- The aircraft maintenance documents were not kept up to date by the operator,
- Poor flight preparation on the part of the pilot who did not notice that the maintenance documents were not up to date,
- The operator was not compliant with the current Brazilian Civil Aviation Authority legislation.

Final Report:

Crash of a Boeing 737-2C3 in Goiânia

Date & Time: Sep 16, 2001 at 1053 LT

Type of aircraft:

Boeing 737-200

Operator:

Registration:

PP-CJN

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

São Paulo – Goiânia

MSN:

21012

YOM:

1974

Flight number:

RG2240

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

68500

Aircraft flight cycles:

65500

Circumstances:

On final approach to Goiânia-Santa Genoveva Airport, the crew encountered poor weather conditions with a limited visibility due to rain. The aircraft landed about 500 metres past the runway threshold but as it was misaligned, the right main gear touched down on the left side of the runway. The crew attempted to steer the plane back onto the runway when the right main gear collapsed. The aircraft went out of control, lost its right engine then its nose gear and came to rest on the runway. All 67 occupants evacuated safely.

Probable cause:

Wrong approach configuration on part of the crew who continued the approach while the aircraft was not properly aligned with the runway centerline.

Crash of an Embraer EMB-820C Navajo in Curitiba

Date & Time: Jun 6, 2001 at 2010 LT

Type of aircraft:

Operator:

Registration:

PT-EFU

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Guarapuava – Curitiba

MSN:

820-031

YOM:

1976

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2600

Captain / Total hours on type:

592.00

Circumstances:

Following an uneventful cargo flight from Guarapuava, the crew started the descent to Curitiba-Bacacheri Airport by night and adverse weather conditions. After touchdown on a wet runway surface, the twin engine aircraft went out of control, overran and collided with a concrete wall. All three occupants were injured, one of the pilot seriously.

Probable cause:

The decision of the crew to land at Curitiba-Bacacheri Airport was not appropriate due to poor weather conditions. The crew underestimated the weather conditions at destination and should take the decision to divert to a more suitable terrain.

Final Report:

Crash of a Embraer EMB-820C Navajo in São Paulo: 1 killed

Date & Time: Jun 5, 2001 at 2030 LT

Type of aircraft:

Oliveira e Silva Táxi Aéreo

Operator:

Registration:

PT-EHL

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

City

Schedule:

Franca – São Paulo

MSN:

820-048

YOM:

1977

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2000

Captain / Total hours on type:

600.00

Aircraft flight hours:

5289

Circumstances:

The aircraft departed Franca Airport in the evening on a cargo flight to São Paulo, carrying one pilot and bank notes. On a night approach to São Paulo-Congonhas Airport, the pilot cancelled the IFR flight plan when he encountered technical problems with the right engine. He shut down the engine and continued the approach to runway 35R without informing ATC of his situation. Too high on the glide, he apparently decided to initiate a go-around when he lost control of the aircraft that rolled to the left, lost height and crashed in a residential area, bursting into flames. The aircraft was destroyed and the pilot was killed. Two people on the ground were injured.

Probable cause:

It was determined that the hydraulic pump on the right engine failed in flight, forcing the pilot to shut the engine down. It was reported that the pilot continued the approach in a single-engine configuration without informing ATC and that the aircraft was too high on the glide and approaching with an excessive speed. The pilot improperly analyzed the aircraft's flight conditions after shutting down the right engine, causing the aircraft to enter an approach configuration that was not compliant with the published procedures.

Final Report:

Crash of a Boeing 707-331C in São Paulo

Date & Time: Mar 7, 2001 at 0030 LT

Type of aircraft:

Boeing 707

Operator:

Registration:

PT-MST

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Belém – Brasilía – São Paulo

MSN:

18711

YOM:

1964

Flight number:

SKC9101

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4200

Captain / Total hours on type:

2543.00

Copilot / Total flying hours:

3858

Copilot / Total hours on type:

361

Aircraft flight hours:

70422

Aircraft flight cycles:

28047

Circumstances:

The aircraft was completing a cargo flight from Belém to São Paulo with an intermediate stop in Brasilía, carrying three crew members and a load of various goods such as mail and fish. While descending to São Paulo-Guarulhos Airport in good weather conditions at an altitude of 10,000 feet, the crew encountered technical problems with the trim system. Several manual controls and tests were conducted and the system worked before failing again between 6,000 and 4,700 feet. The captain decided to continue the approach but the aircraft became unstable and nosed down on short final. It landed hard on runway 09R, causing the undercarriage to be torn off. The aircraft slid for about 1,000 metres then veered off runway to the left and came to rest in a grassy area. All three crew members escaped uninjured while the aircraft was damaged beyond repair.

Probable cause:

The exact cause of the technical problems on the trim system could not be determined with certainty. The following contributing factors were identified:
- The decisions of the crew and more particularly of the captain during the last phase of flight were incorrect,
- The crew training program for emergency situation was incomplete,
- Improper use of flaps and slats on final approach made the situation worse,
- The captain did not follow the procedure determined for such an emergency situation and decided to continue the approach maneuver, increasing the risk margin and placing the airplane in critical operating conditions,
- Due to deviations from the published standard operational procedures, such as failure to complete the approach briefing and not following the approach checklist, the coordination among the flight crew was poor, leading to further deviations and putting the crew in a critical situation.

Final Report:

Crash of an Embraer EMB-820C Navajo in Varginha

Date & Time: Feb 22, 2001 at 1935 LT

Type of aircraft:

Operator:

Registration:

PT-LFP

Flight Phase:

Takeoff (climb)

Flight Type:

Postal (mail)

Survivors:

Site:

Varginha-Major-Brigadeiro Trompowsky

Schedule:

Varginha – Belo Horizonte

MSN:

820-038

YOM:

1977

Location:

Minas Gerais

Country:

Brazil

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

1959

Captain / Total hours on type:

213.00

Copilot / Total flying hours:

658

Copilot / Total hours on type:

276

Circumstances:

The twin engine aircraft departed Varginha-Major-Brigadeiro Trompowsky Airport on a mail flight to Belo Horizonte-Pampulha Airport with two pilots on board. After takeoff, while in initial climb, the right engine lost power. The aircraft lost height and crash landed in an open field. It slid for about 100 metres before coming to rest, bursting into flames. Both pilots escaped with minor injuries and the aircraft was destroyed by fire.

Probable cause:

Loss of power on the right engine for undetermined reasons. The following findings were identified:
- Poor flight preparation on part of the crew,
- The crew did not know the exact weight of the mail/cargo,
- The crew did not have sufficient training/instruction regarding a possible loss of engine power at takeoff,
- Poor engine maintenance as the right engine had experienced power issues in the past that had not been resolved,
- Poor crew coordination,
- When the loss of power occurred on the right engine, the captain asked the copilot to raise the landing gear and preferred to resolve the emergency situation alone,
- Poor evaluation of the aircraft performances on part of the crew in regard of the weight and balance values and CofG.

Final Report:

Crash of a Mitsubishi MU-2B-25 Marquise in Macapá

Date & Time: Feb 10, 2001 at 1230 LT

Type of aircraft:

Mitsubishi MU-2 Marquise

Operator:

Registration:

PT-LEW

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site: