Country
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Pernambuco

Crash of an Airbus A300B4-230F in Recife

Date & Time: Oct 21, 2016 at 0630 LT
Type of aircraft:
Operator:
Registration:
PR-STN
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Recife
MSN:
236
YOM:
1983
Flight number:
STR9302
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11180
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
7300
Copilot / Total hours on type:
800
Circumstances:
Following an uneventful cargo service from São Paulo-Guarulhos Airport, the crew initiated the descent to Recife-Guararapes Airport. On final approach to runway 18, after the aircraft had been configured for landing, at an altitude of 500 feet, the crew was cleared to land. After touchdown, the thrust lever for the left engine was pushed to maximum takeoff power while the thrust lever for the right engine was simultaneously brang to the idle position then to reverse. This asymetric configuration caused the aircraft to veer to the right and control was lost. The airplane veered off runway to the right and, while contacting soft grounf, the nose gear collapsed. The airplane came to rest to the right of the runway and was damaged beyond repair. All four occupants evacuated safely.
Probable cause:
Contributing factors.
- Control skills - undetermined
Inadequate use of aircraft controls, particularly as regards the mode of operation of the Autothrottle in use and the non-reduction of the IDLE power levers at touch down, may have led to a conflict between pilots when performing the landing and the automation logic active during approach. In addition, the use of only one reverse (on the right engine) and placing the left throttle lever at maximum takeoff power resulted in an asymmetric thrust that contributed to the loss of control on the ground.
- Attitude - undetermined
The adoption of practices different from the aircraft manual denoted an attitude of noncompliance with the procedures provided, which contributed to put the equipment in an unexpected condition: non-automatic opening of ground spoilers and asymmetric thrust of the engines. These factors required additional pilot intervention (hand control), which may have made it difficult to manage the circumstances that followed the touch and led to the runway excursion.
- Crew Resource Management - a contributor
The involvement of the PM in commanding the aircraft during the events leading up to the runway excursion to the detriment of its primary responsibility, which would be to monitor systems and assist the PF in conducting the flight, characterized an inefficiency in harnessing the human resources available for the airplane operation. Thus, the improper management of the tasks assigned to each crewmember and the non-observance of the CRM principles delayed the identification of the root cause of the aircraft abnormal behavior.
- Organizational culture - a contributor
The reliance on the crew's technical capacity, based on their previous aviation experience, has fostered an informal organizational environment. This informality contributed to the adoption of practices that differed from the anticipated procedures regarding the management and operation of the aircraft. This not compliance with the procedures highlights a lack of safety culture, as lessons learnt from previous similar accidents (such as those in Irkutsk and Congonhas involving landing using only one reverse and pushing the thrust levers forward), have apparently not been taken into account at the airline level.
- Piloting judgment - undetermined
The habit of not reducing the throttle lever to the IDLE position when passing at 20ft diverged from the procedures contained in the aircraft-operating manual and prevented the automatic opening of ground spoilers. It is possible that the consequences of this adaptation of the procedure related to the operation of the airplane were not adequately evaluated, which made it difficult to understand and manage the condition experienced.
- Perception - a contributor
Failure to perceive the position of the left lever denoted a lowering of the crew's situational awareness, as it apparently only realized the real cause of the aircraft yaw when the runway excursion was already underway.
- Decision-making process - a contributor
An inaccurate assessment of the causes that would justify the behavior of the aircraft during the landing resulted in a delay in the application of the necessary power reduction procedure, that is, repositioning the left engine power lever.
Final Report:

Crash of a Let L-410UVP-E20 in Recife: 16 killed

Date & Time: Jul 13, 2011 at 0654 LT
Type of aircraft:
Operator:
Registration:
PR-NOB
Flight Phase:
Survivors:
No
Schedule:
Recife - Natal - Mossoró
MSN:
92 27 22
YOM:
1992
Flight number:
NRA4896
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
15457
Captain / Total hours on type:
957.00
Copilot / Total flying hours:
2404
Copilot / Total hours on type:
404
Aircraft flight hours:
2126
Aircraft flight cycles:
3033
Circumstances:
At 0650 local time, the aircraft departed from Recife-Guararapes Airport runway 18, destined for Natal, carrying 14passengers and two crewmembers on a regular public transportation flight. During the takeoff, after the aircraft passed over the departure end of the runway, the copilot informed that they would return for landing, preferably on runway 36, and requested a clear runway. The aircraft made a deviation to the left, out of the trajectory, passed over the coastline, and, then, at an altitude of approximately 400ft, started a turn to the right over the sea. After about 90º of turn, upon getting close to the coast line, the aircraft reverted the turn to the left, going farther away from the coast line. After a turn of approximately 270º, it leveled the wings and headed for the airport area. The copilot informed, while the aircraft was still over the sea, that they would make an emergency landing on the beach. Witnesses reported that, as the aircraft was crossing over the coast line, the left propeller seemed to be feathered and turning loosely. At 0654 local time, the aircraft crashed into the ground in an area without buildings, between Boa Viagem Avenue and Visconde de Jequitinhonha Avenue, at a distance of 1,740 meters from the runway 36 threshold. A raging post-impact fire occurred and all 16 occupants were killed.
Probable cause:
Human Factors
Medical Aspect
- Anxiety
The perception of danger especially by the first officer affected the communication between the pilots and may have inhibited a more assertive attitude, which could have led to an emergency landing on the beach, minimizing the consequences of the accident.
Psychological Aspect
- Attitude
Operational decisions during the emergency may have resulted from the high confidence level, that the captain had acquired in years of flying and experience in aviation, as well as the captain's resistance to accept opinions different to his own.
- Emotional state
According to CVR recordings there was a high level of anxiety and tension even before the abnormal situation. These components may have influenced the judgment of conditions affecting the operation of the aircraft.
- Decision making
The persistence to land on runway 36 during the emergency, even though the first officer recognized the conditions no longer permitted to reach the airport, reflects misjudgment of operational information present at the time.
- Signs of stress
The unexpected emergency at takeoff and the lack of preparation for dealing with it may have invoked a level of stress with the crew, that negatively affected the operational response.
Psychosocial Information
- Interpersonal relations
The historical differences between the two pilots possibly hindered the exchange of information and created a barrier to deal with the adverse situation.
- Dynamic team
The present diverging intentions of how to proceed clearly show cooperation and management issues in the cockpit. This prevented the choice of best alternative to achieve a safe emergency landing when there were no options left to reach the airport.
- Company Culture
The company was informally divided into two groups, whose interaction was impaired. It is possible that this problem of interaction continued into the cockpit management during the in flight emergency, with one pilot belonging to one and the other to the other group.
Organizational Information
- Education and Training
Deficiencies of training provided by the operator affected the performance of the crew, who had not been sufficiently prepared for the safe conduct of flight in case of emergency.
- Organizational culture
The actions taken by the company indicate informality, which resulted in incomplete operational training and attitudes that endangered the safety.
Operational Aspects
According to data from the flight recorder the rudder pedal inputs were inadequate to provide sufficient rudder deflection in order to compensate for asymmetric engine power.
The values of side slip reached as result of inadequate rudder pedal inputs penalized the performance of the aircraft preventing further climb or even maintaining altitude.
In the final phase of the flight, despite the airspeed decaying below Vmca, despite continuous stall warnings and despite calls by the first officer to not hold the nose up in order to not stall the captain continued pitch up control inputs until the aircraft reached 18 degrees nose up attitude and entered stall.
- Crew Coordination
The delay in retracting the landing gear after the first instruction by the captain, the instruction of the captain to feather the propeller when the propeller had already been feathered as well as the first officer's request the captain should initiate the turn back when the aircraft was already turning are indicative that the crew tasks and actions were not coordinated.
Emergency procedures provided in checklists were not executed and there was no consensus in the final moments of the flight, whether the best choice (least critical option) was to return to the runway or land on the beach.
- Oblivion
It is possible in response to the emergency and influenced by anxiety, that the crew may have forgotten to continue into the 3rd segment of the procedure provided for engine failure on takeoff at or above V1 while trying to return to the airfield shortly after completion of the 2nd segment while at 400ft.
- Pilot training
The lack of training of engine failures on takeoff at or above V1, similar as is recommended in the training program, led to an inadequate pilot response to the emergency. The pilots did not follow the recommended flight profile and did execute the checklist items to be carried out above 400 feet.
- Pilot decisions
The pilots assessed that the priority was to return to land in opposite direction of departure and began the turn back at 400 feet, which added to the difficulty of flying the aircraft. At 400 feet the aircraft maintained straight flight and a positive rate of climb requiring minor flight control inputs only, which would have favored the completion of the emergency check list items in accordance with recommendations by the training program.
After starting the turn the crew would needed to adjust all flight controls to maintain intended flight trajectory in addition to working the checklists, the turn thus increased workload. It is noteworthy that the remaining engine developed sufficient power to sustain flight.
- Supervision by Management
The supervision by management did not identify that the training program provided to pilots failed to address engine failure above V1 while still on the ground and airborne.
It was not identified that the software adopted by the company to dispatch aircraft used the maximum structural weight (6,600 kg) as maximum takeoff weight for departures from Recife.
On the day of the accident the aircraft was limited in takeoff weight due to ambient temperature. Due to the software error the aircraft took off with more than the maximum allowable takeoff weight degrading climb performance.
Mechanical Aspects
- Aircraft
Following the hypothesis that the fatigue process had already started when the turbine blade was still attached to the Russia made engine, the method used by the engine manufacturer for assessment to continue use of turbine blades was not able to ensure sufficient quality of the blade, that had been mounted into position 27 of the left hand engine's Gas Generator Turbine's disk.
- Aircraft Documentation
The documentation of the aircraft by the aircraft manufacturer translated into the English language did not support proper operation by having confusing texts with different content for the same items in separate documents as well as translation errors. This makes the documentation difficult to understand, which may have contributed to the failure to properly implement the engine failure checklists on takeoff after V1.
An especially concerning item is the "shutdown ABC (Auto Bank Control)", to be held at 200 feet height, the difference between handling instructed by the checklist and provided by the flight crew manual may have contributed to the non-performance by the pilots, aggravating performance of the aircraft.
Final Report:

Crash of an Airbus A330-203 off Fernando de Noronha: 228 killed

Date & Time: Jun 1, 2009 at 0014 LT
Type of aircraft:
Operator:
Registration:
F-GZCP
Flight Phase:
Survivors:
No
Schedule:
Rio de Janeiro – Paris
MSN:
660
YOM:
2005
Flight number:
AF447
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
216
Pax fatalities:
Other fatalities:
Total fatalities:
228
Captain / Total flying hours:
6547
Captain / Total hours on type:
4479.00
Copilot / Total flying hours:
2936
Copilot / Total hours on type:
807
Aircraft flight hours:
18870
Aircraft flight cycles:
2644
Circumstances:
On Sunday 31 May 2009, the Airbus A330-203 registered F-GZCP operated by Air France was programmed to perform scheduled flight AF 447 between Rio de Janeiro-Galeão and Paris Charles de Gaulle. Twelve crew members (3 flight crew, 9 cabin crew) and 216 passengers were on board. The departure was planned for 22 h 00. At around 22 h 10, the crew was cleared to start up engines and leave the stand. Takeoff took place at 22 h 29. The Captain was Pilot Not Flying (PNF); one of the copilots was Pilot Flying (PF). At the start of the Cockpit Voice Recorder (CVR) recording, shortly after midnight, the aeroplane was in cruise at flight level 350. Autopilot 2 and auto-thrust were engaged. Auto fuel transfer in the “trim tank” was carried out during the climb. The flight was calm. At 1 h 35, the aeroplane arrived at INTOL point and the crew left the Recife frequency to change to HF communication with the Atlántico Oceanic control centre. A SELCAL test was successfully carried out, but attempts to establish an ADS-C connection with DAKAR Oceanic failed. Shortly afterwards, the co-pilot modified the scale on his Navigation Display (ND) from 320 NM to 160 NM and noted “…a thing straight ahead”. The Captain confirmed and the crew again discussed the fact that the high temperature meant that they could not climb to flight level 370. At 1 h 45, the aeroplane entered a slightly turbulent zone, just before SALPU point. Note: At about 0 h 30 the crew had received information from the OCC about the presence of a convective zone linked to the inter-tropical convergence zone (ITCZ) between SALPU and TASIL. The crew dimmed the lighting in the cockpit and switched on the lights “to see”. The co-pilot noted that they were “entering the cloud layer” and that it would have been good to be able to climb. A few minutes later, the turbulence increased slightly in strength. Shortly after 1 h 52, the turbulence stopped. The co-pilot again drew the Captain’s attention to the REC MAX value, which had then reached flight level (FL) 375. A short time later, the Captain woke the second co-pilot and said “[…] he’s going to take my place”. At around 2 h 00, after leaving his seat, the Captain attended the briefing between the two co-pilots, during which the PF (seated on the right) said specifically that “well the little bit of turbulence that you just saw we should find the same ahead we’re in the cloud layer unfortunately we can’t climb much for the moment because the temperature is falling more slowly than forecast” and that “the logon with DAKAR failed”. Then the Captain left the cockpit. The aeroplane approached the ORARO point. It was flying at flight level 350 and at Mach 0.82. The pitch attitude was about 2.5 degrees. The weight and balance of the aeroplane were around 205 tonnes and 29%. The two copilots again discussed the temperature and the REC MAX. The turbulence increased slightly. At 2 h 06, the PF called the cabin crew, telling them that “in two minutes we ought to be in an area where it will start moving about a bit more than now you’ll have to watch out there” and he added “I’ll call you when we’re out of it”. At around 2 h 08, the PNF proposed “go to the left a bit […]”. The HDG mode was activated and the selected heading decreased by about 12 degrees in relation to the route. The PNF changed the gain adjustment on his weather radar to maximum, after noticing that it was in calibrated mode. The crew decided to reduce the speed to about Mach 0.8 and engine de-icing was turned on. At 2 h 10 min 05, the autopilot then the auto-thrust disconnected and the PF said “I have the controls”. The aeroplane began to roll to the right and the PF made a nose-up and left input. The stall warning triggered briefly twice in a row. The recorded parameters showed a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS). The flight control law reconfigured from normal to alternate. The Flight Directors (FD) were not disconnected by the crew, but the crossbars disappeared. Note: Only the speeds displayed on the left side and on the ISIS are recorded on the FDR; the speed displayed on the right side is not recorded. At 2 h 10 min 16, the PNF said “we’ve lost the speeds ” then “alternate law protections”. The PF made rapid and high amplitude roll control inputs, more or less from stop to stop. He also made a nose-up input that increased the aeroplane’s pitch attitude up to 11° in ten seconds. Between 2 h 10 min 18 and 2 h 10 min 25, the PNF read out the ECAM messages in a disorganized manner. He mentioned the loss of autothrust and the reconfiguration to alternate law. The thrust lock function was deactivated. The PNF called out and turned on the wing anti-icing. The PNF said that the aeroplane was climbing and asked the PF several times to descend. The latter then made several nose-down inputs that resulted in a reduction in the pitch attitude and the vertical speed. The aeroplane was then at about 37,000 ft and continued to climb. At about 2 h 10 min 36, the speed displayed on the left side became valid again and was then 223 kt; the ISIS speed was still erroneous. The aeroplane had lost about 50 kt since the autopilot disconnection and the beginning of the climb. The speed displayed on the left side was incorrect for 29 seconds. At 2 h 10 min 47, the thrust controls were pulled back slightly to 2/3 of the IDLE/CLB notch (85% of N1). Two seconds later, the pitch attitude came back to a little above 6°, the roll was controlled and the angle of attack was slightly less than 5°. The aeroplane’s pitch attitude increased progressively beyond 10 degrees and the plane started to climb. From 2 h 10 min 50, the PNF called the Captain several times. At 2 h 10 min 51, the stall warning triggered again, in a continuous manner. The thrust levers were positioned in the TO/GA detent and the PF made nose-up inputs. The recorded angle of attack, of around 6 degrees at the triggering of the stall warning, continued to increase. The trimmable horizontal stabilizer (THS) began a nose-up movement and moved from 3 to 13 degrees pitch-up in about 1 minute and remained in the latter position until the end of the flight. Around fifteen seconds later, the ADR3 being selected on the right side PFD, the speed on the PF side became valid again at the same time as that displayed on the ISIS. It was then at 185kt and the three displayed airspeeds were consistent. The PF continued to make nose-up inputs. The aeroplane’s altitude reached its maximum of about 38,000 ft; its pitch attitude and angle of attack were 16 degrees. At 2 h 11 min 37, the PNF said “controls to the left”, took over priority without any callout and continued to handle the aeroplane. The PF almost immediately took back priority without any callout and continued piloting. At around 2 h 11 min 42, the Captain re-entered the cockpit. During the following seconds, all of the recorded speeds became invalid and the stall warning stopped, after having sounded continuously for 54 seconds. The altitude was then about 35,000 ft, the angle of attack exceeded 40 degrees and the vertical speed was about -10,000 ft/min. The aeroplane’s pitch attitude did not exceed 15 degrees and the engines’ N1’s were close to 100%. The aeroplane was subject to roll oscillations to the right that sometimes reached 40 degrees. The PF made an input on the side-stick to the left stop and nose-up, which lasted about 30 seconds. At 2 h 12 min 02, the PF said, “I have no more displays”, and the PNF “we have no valid indications”. At that moment, the thrust levers were in the IDLE detent and the engines’ N1’s were at 55%. Around fifteen seconds later, the PF made pitch-down inputs. In the following moments, the angle of attack decreased, the speeds became valid again and the stall warning triggered again. At 2 h 13 min 32, the PF said, “[we’re going to arrive] at level one hundred”. About fifteen seconds later, simultaneous inputs by both pilots on the side-sticks were recorded and the PF said, “go ahead you have the controls”. The angle of attack, when it was valid, always remained above 35 degrees. From 2 h 14 min 17, the Ground Proximity Warning System (GPWS) “sink rate” and then “pull up” warnings sounded. The recordings stopped at 2 h 14 min 28. The last recorded values were a vertical speed of -10,912 ft/min, a ground speed of 107 kt, pitch attitude of 16.2 degrees nose-up, roll angle of 5.3 degrees left and a magnetic heading of 270 degrees. No emergency message was transmitted by the crew. The wreckage was found at a depth of 3,900 metres on 2 April 2011 at about 6.5 NM on the radial 019 from the last position transmitted by the aeroplane. Both CVR and DFDR were found 23 months after the accident, in May 2011 at a depth of 3,900 metres. The final report was published in July 2012.
Probable cause:
The obstruction of the Pitot probes by ice crystals during cruise was a phenomenon that was known but misunderstood by the aviation community at the time of the accident. From an operational perspective, the total loss of airspeed information that resulted from this was a failure that was classified in the safety model. After initial reactions that depend upon basic airmanship, it was expected that it would be rapidly diagnosed by pilots and managed where necessary by precautionary measures on the pitch attitude and the thrust, as indicated in the associated procedure. The occurrence of the failure in the context of flight in cruise completely surprised the pilots of flight AF 447. The apparent difficulties with aeroplane handling at high altitude in turbulence led to excessive handling inputs in roll and a sharp nose-up input by the PF. The destabilization that resulted from the climbing flight path and the evolution in the pitch attitude and vertical speed was added to the erroneous airspeed indications and ECAM messages, which did not help with the diagnosis. The crew, progressively becoming de-structured, likely never understood that it was faced with a 'simple' loss of three sources of airspeed information. In the minute that followed the autopilot disconnection, the failure of the attempts to understand the situation and the de-structuring of crew cooperation fed on each other until the total loss of cognitive control of the situation. The underlying behavioral hypotheses in classifying the loss of airspeed information as 'major' were not validated in the context of this accident. Confirmation of this classification thus supposes additional work on operational feedback that would enable improvements, where required, in crew training, the ergonomics of information supplied to them and the design of procedures. The aeroplane went into a sustained stall, signaled by the stall warning and strong buffet. Despite these persistent symptoms, the crew never understood that they were stalling and consequently never applied a recovery manoeuvre. The combination of the ergonomics of the warning design, the conditions in which airline pilots are trained and exposed to stalls during their professional training and the process of recurrent training does not generate the expected behavior in any acceptable reliable way. In its current form, recognizing the stall warning, even associated with buffet, supposes that the crew accords a minimum level of 'legitimacy' to it. This then supposes sufficient previous experience of stalls, a minimum of cognitive availability and understanding of the situation, knowledge of the aeroplane (and its protection modes) and its flight physics. An examination of the current training for airline pilots does not, in general, provide convincing indications of the building and maintenance of the associated skills. More generally, the double failure of the planned procedural responses shows the limits of the current safety model. When crew action is expected, it is always supposed that they will be capable of initial control of the flight path and of a rapid diagnosis that will allow them to identify the correct entry in the dictionary of procedures. A crew can be faced with an unexpected situation leading to a momentary but profound loss of comprehension. If, in this case, the supposed capacity for initial mastery and then diagnosis is lost, the safety model is then in 'common failure mode'. During this event, the initial inability to master the flight path also made it impossible to understand the situation and to access the planned solution.
Thus, the accident resulted from the following succession of events:
- Temporary inconsistency between the airspeed measurements, likely following the obstruction of the Pitot probes by ice crystals that, in particular, caused the autopilot disconnection and the reconfiguration to alternate law;
- Inappropriate control inputs that destabilized the flight path;
- The lack of any link by the crew between the loss of indicated speeds called out and the appropriate procedure;
- The late identification by the PNF of the deviation from the flight path and the insufficient correction applied by the PF;
- The crew not identifying the approach to stall, their lack of immediate response and the exit from the flight envelope;
- The crew’s failure to diagnose the stall situation and consequently a lack of inputs that would have made it possible to recover from it.
These events can be explained by a combination of the following factors:
- The feedback mechanisms on the part of all those involved that made it impossible:
* To identify the repeated non-application of the loss of airspeed information procedure and to remedy this,
* To ensure that the risk model for crews in cruise included icing of the Pitot probes and its consequences;
- The absence of any training, at high altitude, in manual aeroplane handling and in the procedure for 'Vol avec IAS douteuse';
- Task-sharing that was weakened by:
* Incomprehension of the situation when the autopilot disconnection occurred,
* Poor management of the startle effect that generated a highly charged emotional factor for the two copilots;
- The lack of a clear display in the cockpit of the airspeed inconsistencies identified by the computers;
- The crew not taking into account the stall warning, which could have been due to:
* A failure to identify the aural warning, due to low exposure time in training to stall phenomena, stall warnings and buffet,
* The appearance at the beginning of the event of transient warnings that could be considered as spurious,
* The absence of any visual information to confirm the approach-to-stall after the loss of the limit speeds,
* The possible confusion with an overspeed situation in which buffet is also considered as a symptom,
* Flight Director indications that may led the crew to believe that their actions were appropriate, even though they were not,
* The difficulty in recognizing and understanding the implications of a reconfiguration in alternate law with no angle of attack protection.
Final Report:

Crash of a Beechcraft 200 Super King Air in Recife: 2 killed

Date & Time: Nov 23, 2008 at 1115 LT
Operator:
Registration:
PT-OSR
Survivors:
Yes
Site:
Schedule:
Teresina - Recife
MSN:
BB-784
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10000
Circumstances:
Following an uneventful flight from Teresina, the crew started the approach to Recife-Guararapes Airport runway 18. On final, both engines failed simultaneously. The aircraft stalled and crashed in a residential area located 5 km from the runway threshold. A passenger and a pilot were killed while eight others occupants were injured. There were no victims on the ground while the aircraft was destroyed.
Probable cause:
Double engine failure caused by a fuel exhaustion. The following contributing factors were identified:
- Poor flight planning,
- The crew failed to add sufficient fuel prior to departure from Teresina Airport,
- The fuel quantity was insufficient for the required distance,
- The crew failed to follow the published procedures,
- Overconfidence from the crew,
- Poor organisational culture on part of the operator,
- Lack of discipline and poor judgment on part of the crew,
- Lack of supervision.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Recife

Date & Time: Oct 21, 1999 at 0745 LT
Registration:
PP-SEA
Flight Type:
Survivors:
Yes
Schedule:
Recife – Patos – Sousa – Mossoró – Caicó – Currais Novos – Recife
MSN:
500-1801-16
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
100
Circumstances:
The twin engine aircraft departed Recife-Guararapes Airport in the early morning on a round cargo trip with a load of medicines. Complete stops were made in Patos, Sousa, Mossoró, Caicó and Currais Novos. On the last leg from Currais Novos to Recife, while approaching Recife-Guararapes Airport, both engines failed simultaneously after a total flight of 3 hours and 50 minutes. The crew declared an emergency and attempted to land immediately when the aircraft collided with trees and power cables before crashing in a wooded area located 17 km short of runway 18. Both pilots were injured and the aircraft was damaged beyond repair.
Probable cause:
Double engine failure on final approach due to fuel exhaustion. The following contributing factors were identified:
- Poor flight preparation and planning,
- The crew was overconfident,
- The crew miscalculated the total fuel quantity needed for the entire mission,
- Wrong fuel consumption calculation,
- Taxing time and wind component were not taken into consideration in the fuel consumption calculation,
- Incorrect values relative to the aircraft performances,
- Poor crew resources management.
Final Report:

Crash of an Embraer P-95B Bandeirante in Caruaru: 9 killed

Date & Time: Nov 17, 1996 at 1700 LT
Type of aircraft:
Operator:
Registration:
7102
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Salvador - Natal
MSN:
110-487
YOM:
1989
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The aircraft was completing a flight from Salvador to Natal in formation with three other similar aircraft. En route, while in cruising altitude, the aircraft's tail was struck by the propeller of another aircraft positioned behind. A part of the tail detached and the aircraft entered an uncontrolled descent before crashing, bursting into flames. All nine occupants were killed.

Crash of a Boeing 707-387B in Recife

Date & Time: Jan 31, 1993
Type of aircraft:
Operator:
Registration:
LV-ISA
Survivors:
Yes
Schedule:
Maceió – Fortaleza
MSN:
19238
YOM:
1966
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route from Maceió to Fortaleza, while in cruising altitude, the crew reported hydraulic problems and was cleared to divert to Recife-Guararapes Airport for an emergency landing. On approach, the crew was forced to lower the gear manually but it was not possible to establish if they were locked down or not. In accordance with ATC, the crew completed a low pass over the airport and ATC confirmed all three gear were down. A second approach was completed and the aircraft landed smoothly. Nevertheless, following a course of few dozen metres, the right main gear 'collapsed' and entered its wheel well. The aircraft rolled to the right, veered off runway then struck a concrete block, causing the nose gear to collapse. All 168 occupants were evacuated safely while the aircraft was damaged beyond repair.

Crash of an Embraer R-95 Bandeirante in Recife: 5 killed

Date & Time: Oct 23, 1992 at 1015 LT
Type of aircraft:
Operator:
Registration:
2243
Flight Type:
Survivors:
No
Schedule:
Recife - Recife
MSN:
110-138
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew was taking part to the Aviation Day and was involved in a demonstration mission on behalf of the 2nd Regional Air Command. On approach, the aircraft crashed in unknown circumstances in the garden of a military hospital located about 2 km from the airport. All five occupants were killed.

Crash of an Embraer EMB-110P1 Bandeirante in Recife: 17 killed

Date & Time: Nov 11, 1991 at 2143 LT
Operator:
Registration:
PT-SCU
Flight Phase:
Survivors:
No
Site:
Schedule:
Recife - Maceió - Aracajú - Salvador
MSN:
110-314
YOM:
1980
Flight number:
NES115
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total flying hours:
4295
Captain / Total hours on type:
901.00
Copilot / Total flying hours:
2604
Copilot / Total hours on type:
1401
Aircraft flight hours:
3973
Circumstances:
During the takeoff roll on runway 36 at Recife-Guararapes Airport, the right engine failed. The crew decided to continue the takeoff procedure and completed the rotation after a course of 900 metres. Thirty seconds after rotation, at a height of about 100 feet, the right engine caught fire and exploded. The crew lost control of the airplane that crashed in the district of Ipsep near the airport. The aircraft and several buildings were destroyed. All 15 occupants as well as two people on the ground were killed.
Probable cause:
The accident was the consequence of the failure of the right engine during takeoff. It was determined that the temperature indicator for the right engine was faulty, displaying a lower than actual temperature. The engine operated for some time at high temperatures because of the faulty system. It was also found that, after completion, some maintenance and inspection tasks were just signed by the maintenance engineer. Signatures from the maintenance inspector were missing.
The following contributing factors were reported:
- Poor crew reaction to an emergency situation,
- Poor maintenance,
- Manufacturing deficiency,
- The crew failed to abort the takeoff procedure.
Final Report:

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: