Crash of a Learjet 25D in Brasilía: 7 killed

Date & Time: Mar 18, 1991
Type of aircraft:
Registration:
PT-LLL
Survivors:
No
Schedule:
Uberaba - Brasilía
MSN:
25-258
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
On a night approach to Brasilía Airport, the aircraft crashed 8 km short of runway. All seven occupants were killed.

Crash of a Learjet 35A in Uberlândia

Date & Time: Mar 15, 1991 at 2107 LT
Type of aircraft:
Operator:
Registration:
PT-LIH
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Uberlândia
MSN:
35-433
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3850
Captain / Total hours on type:
550.00
Copilot / Total flying hours:
15175
Copilot / Total hours on type:
525
Circumstances:
The aircraft departed São Paulo-Congonhas Airport on an ambulance flight to Uberlândia, carrying two doctors and two pilots who should pick-up a patient. The copilot was pilot flying. This was his first flight on a Learjet without an instructor. This was against regulations since the copilot was not fully qualified yet and the captain was not qualified to act as an instructor. Upon arrival at Uberlândia, weather conditions were poor with a low ceiling at 100 meters (clouds 8/8), fog and an horizontal visibility less than 200 meters (below minimums weather conditions). The crew abandoned the approach and initiated a go-around procedure. Few minutes later, a second approach was also abandoned. Rather than diverting to the alternate airport, the crew attempted a third approach when the aircraft struck the ground and crashed short of runway threshold. All four occupants were seriously injured and the aircraft was destroyed.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Poor flight preparation and planning,
- Poor approach planning,
- Wrong approach configuration,
- Poor crew coordination,
- Lack of visibility due to the night associated to below minimums weather conditions,
- The crew failed to initiate a go-around and to divert to the alternate airport,
- Poor crew resources management,
- Non observation of operational procedures,
- Lack of supervision on part of the captain,
- Poor operational organization on part of the operator.
Final Report:

Crash of a Learjet 25C in Belo Horizonte: 5 killed

Date & Time: Jan 11, 1991 at 2040 LT
Type of aircraft:
Registration:
PT-KKV
Survivors:
No
Schedule:
Brasília – Belo Horizonte
MSN:
25-172
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
On final approach to Belo Horizonte-Pampulha Airport, the crew encountered poor weather conditions with heavy rain falls. On short final, the aircraft entered an uncontrolled descent and crashed near a motorway located few hundred meters short of runway. The aircraft was destroyed and all five occupants were injured. Three minutes prior to the accident, the crew reported to ATC that all was ok on board.

Crash of a De Havilland CC-115 Buffalo in Rio de Janeiro: 9 killed

Date & Time: Nov 12, 1990 at 0920 LT
Type of aircraft:
Operator:
Registration:
2350
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro – Campo de Marte – Anápolis – Brasília
MSN:
15
YOM:
1968
Country:
Crew on board:
10
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Shortly after takeoff from runway 15, while in initial climb, the aircraft banked right and crashed about 300 meters from the apron, bursting into flames. A crew member was injured while nine other occupants were killed.

Crash of an Embraer EMB-110P1 Bandeirante off Fernando de Noronha: 12 killed

Date & Time: Sep 20, 1990 at 1940 LT
Operator:
Registration:
PT-FAW
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fernando de Noronha - Recife
MSN:
110-368
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The copilot was preparing the flight as the captain came late in the cockpit. The crew precipitated the departure and after takeoff from runway 12, while climbing by night, the aircraft rolled to the right, entered an uncontrolled descent and crashed in the Atlantic Ocean few hundred meters offshore. The aircraft was destroyed upon impact and all 12 occupants were killed.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The crew suffered a spatial disorientation during initial climb,
- The operator was not equipped with effective systems for monitoring and training of personnel,
- Deficiencies in instruction,
- Poor crew coordination,
- The crew probably failed to follow the pre-takeoff checklist,
- Lack of crew experience on the type of aircraft,
- The inadequate assessment of certain operational aspects during the mission and the use of own piloting standards.
Final Report:

Crash of a Beechcraft 65-B80 Queen Air in Sitío da Velha: 3 killed

Date & Time: Sep 15, 1990 at 1430 LT
Type of aircraft:
Registration:
PT-LGE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Uaicas - Pião
MSN:
LD-374
YOM:
1967
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total hours on type:
300.00
Circumstances:
En route from Uaicas to Pião, the pilot encountered problems with the right engine and decided to divert to Sítio da Velha Airport where he landed without further problems. On ground, one of the passenger who was a mechanic proceeded to a control of the right engine but did not find any anomalies. It was decided to take off but one of the passenger decided not to board. Shortly after takeoff, while climbing to a height of about 200 feet, the aircraft banked right and crashed few hundred meters from the runway end, bursting into flames. All three occupants were killed.
Probable cause:
It was determined that the right engine failed due to fuel exhaustion, the fuel tank being empty.

Crash of a Fairchild-Hiller FH-227B in Altamira: 22 killed

Date & Time: Jun 6, 1990 at 0529 LT
Type of aircraft:
Operator:
Registration:
PT-ICA
Survivors:
Yes
Schedule:
Belém – Altamira – Santarem – Itaituba – Alta Floresta – Cuiabá
MSN:
570
YOM:
1967
Flight number:
TAB814
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
22
Circumstances:
The approach to Altamira Airport was completed by night and marginal weather conditions. Despite the visibility was limited with the presence of fog bank on final, the crew decided to continue under VFR mode. On short final, the aircraft was too low, struck trees and crashed 850 meters short of runway 07. Both pilots and 20 passengers were killed while 22 other occupants were injured.
Probable cause:
The accident was the consequence of the following factors:
- Adverse weather conditions,
- Poor approach planning,
- Poor judgement,
- Poor flight discipline as the crew failed to follow ATC instructions,
- Influence of environment as the region was conducive to the formation of fog,
- The captain had sufficient rest time but his last sleep period was less than five hours,
- The captain was going through a period in which he showed boredom, aggressiveness and demotivation.

Crash of a Beechcraft C90A King Air in Manaus: 7 killed

Date & Time: May 30, 1990 at 1500 LT
Type of aircraft:
Operator:
Registration:
N31434
Survivors:
No
Schedule:
Pitinga - Manaus
MSN:
LJ-1186
YOM:
1988
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The approach to Manaus-Eduardo Gomes was completed in heavy rain falls. On short final, the crew failed to realize his altitude was too low when the aircraft struck an element of the approach light system and crashed 200 meters short of runway, bursting into flames. All seven occupants were killed.

Crash of a Rockwell Aero Commander 560 in Porto Velho: 5 killed

Date & Time: May 21, 1990
Registration:
PT-JFZ
Flight Type:
Survivors:
No
MSN:
560-0185
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Crashed on final approach to Porto Velho Airport for unknown reasons. All five occupants were killed. It is believed all occupants were intoxicated at the time of the accident.

Crash of a Learjet 25C in Juiz de Fora: 2 killed

Date & Time: Apr 6, 1990 at 1503 LT
Type of aircraft:
Registration:
PT-CMY
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro – Juiz de Fora – Belo Horizonte – Monte Carlos
MSN:
25-108
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Copilot / Total hours on type:
9
Circumstances:
The aircraft departed Rio de Janeiro-Santos Dumont Airport on a cargo flight to Monte Carlos with intermediate stops in Juiz de Fora and Belo Horizonte, carrying two passengers, two pilots and a load of bank notes. Because the crew failed to prepare the flight according to procedures, the aircraft left Rio de Janeiro with a total weight in excess of 711 kilos. Following a poor flight and approach planning, the crew failed to make the appropriate landing calculations and upon arrival, the total weight of the aircraft was 946 kilos above the max landing weight. The aircraft landed on a wet runway and after touchdown, the spoilers did not deployed. Unable to stop within the remaining distance, the aircraft overran, went down an embankment and came to rest in a plantation, bursting into flames. A pilot and a passenger were killed while both other occupants were injured. The aircraft was destroyed.
Probable cause:
It was determined that the accident was the consequence of the following factors:
- Poor flight preparation,
- Poor flight planning,
- Poor approach planning,
- The crew failed to calculate the landing distance and performances,
- Poor crew coordination,
- Poor judgement on part of the crew about the existing flight conditions,
- Lack of supervision,
- Lack of crew training,
- Poor crew experience on such type of aircraft,
- The crew failed to initiate a go-around procedure following a wrong landing configuration.