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Crash of an Embraer EMB-110P1 Bandeirante in Coari

Date & Time: Apr 21, 2008 at 1500 LT
Operator:
Registration:
PT-OCV
Survivors:
Yes
Schedule:
Manaus – Carauari
MSN:
110-359
YOM:
1981
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16442
Captain / Total hours on type:
2519.00
Copilot / Total flying hours:
1132
Copilot / Total hours on type:
364
Circumstances:
The twin engine aircraft departed Manaus-Eduardo Gomes Airport on a flight to Carauari, carrying 15 passengers and two pilots. About 50 minutes into the flight, while cruising at an altitude of 8,500 feet, the right engine failed. The crew elected several times to restart it but without success. After the crew informed ATC about his situation, he was cleared to divert to Coari Airport located about 37 km from his position. Because the aircraft was overloaded and one engine was inoperative, the crew was approaching Coari Airport runway 28 with a speed higher than the reference speed. The aircraft landed too far down the runway, about 700 metres past the runway 28 threshold (runway 28 is 1,600 metres long). After touchdown, directional control was lost. The airplane veered off runway to the left and while contacting a drainage ditch, the undercarriage were torn off and the aircraft came to rest 20 metres further. All 17 occupants were evacuated, among them nine were injured. The aircraft was damaged beyond repair.
Probable cause:
The failure of the right engine was the result of the failure of the fuel pump due to poor maintenance and a possible use beyond prescribed limits. The presence of iron oxide inside and outside the fuel pump as well as the lack of cleanliness of the internal components indicates a probable lack of maintenance. When the right engine stopped running, the generator No. 1 was then responsible for powering the aircraft's electrical system. As the latter was not in good working order, the primary generator could not withstand the overload and ceased to function, leaving only the battery to power the entire electrical system. To maintain power to critical systems, the crew would have had to select the backup power system. Since after the engine stopped, there was no monitoring of the electrical system, the pilots only realized the failure of the electrical system when they attempted to extend the landing gears. The emergency hydraulic system was then used to lower the gears, after which the crew did not return the system selection valve to the 'normal' position, resulting in the brakes and the steering systems to be inoperative after landing. The chain of failures may be associated with not reading the checklist when performing procedures after the engine failure.
The following contributing factors were identified:
- Poor flight preparation,
- The crew failed to follow the SOP's, and took the decision to initiate the flight with an aircraft that was overloaded by 503 kilos,
- When the emergency situation presented itself to the crew, they failed to follow the checklist,
- On an organizational level, the company did not have an effective personnel training system in place, so that the crew did not have sufficient skills to respond to emergency situations,
- Because the aircraft was overloaded and that one engine was inoperative, the crew was forced to complete the approach with a speed higher than the reference speed,
- An improper use of the controls allowed the aircraft to land 700 meters past the runway 28 threshold, reducing the landing distance available,
- The crew focused their attention on the failure of the right engine and did not identify the failure of the electrical system, which delayed their tasks assignment, all made worse by the failure to comply with the checklist,
- The operations cleared the crew to start the flight despite the fact that the aircraft was overloaded on takeoff based on weight and balance documents,
- The crew did not prepare the flight according to published procedures and did not consider the total weight of the aircraft in relation to the number of passengers on board and the volume of fuelin the tanks, which resulted in an aircraft to be overloaded by 503 kilos and contributed to the failure of the right engine,
- A lack of maintenance on the part of the operator.
Final Report:

Crash of an Embraer EMB-120ER Brasília near Manaus: 33 killed

Date & Time: May 14, 2004 at 1835 LT
Type of aircraft:
Operator:
Registration:
PT-WRO
Survivors:
No
Schedule:
São Paulo de Olivença – Tabatinga – Tefé – Manaus
MSN:
120-070
YOM:
1988
Flight number:
RLE4815
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
30
Pax fatalities:
Other fatalities:
Total fatalities:
33
Captain / Total flying hours:
19069
Captain / Total hours on type:
5819.00
Copilot / Total flying hours:
11927
Copilot / Total hours on type:
4637
Circumstances:
While descending to Manaus-Eduardo Gomes Airport following an uneventful flight from Tefé, the aircraft was correctly established on the ILS when the crew was instructed by ATC to initiate a go-around and to follow a holding pattern as the priority was given to an ambulance flight. The crew made a left turn heading 060° and continued the descent after passing 2,000 feet when the aircraft struck the ground and crashed about 33 km from the airport. The aircraft disintegrated on impact and all 33 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew continued the descent below 2,000 feet until the aircraft impacted ground. The following contributing factors were identified:
- The crew reported his altitude at 2,000 feet while the real altitude of the airplane was 1,300 feet,
- The crew continued the descent until final impact,
- The crew did not react to the GPWS alarm that sounded four times when the aircraft reached the altitude of 400 feet,
- No corrective action was taken by the crew,
- Lack of crew coordination,
- Poor approach planning that led the aircraft descending to a critical altitude,
- Lack of supervision,
- Operational deficiencies.
Final Report:

Crash of an Embraer EMB-120ER Brasília in Rio Branco: 23 killed

Date & Time: Aug 30, 2002 at 1800 LT
Type of aircraft:
Operator:
Registration:
PT-WRQ
Survivors:
Yes
Schedule:
Cruzeiro do Sul – Tarauacá – Rio Branco
MSN:
120-043
YOM:
1987
Flight number:
RLE4823
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
9315
Captain / Total hours on type:
4560.00
Copilot / Total flying hours:
4242
Copilot / Total hours on type:
3585
Circumstances:
Following an uneventful flight from Tarauacá, the crew started the descent to Rio Branco-Presidente Médici Airport in limited visibility due to the night and rain falls. On final, the aircraft descended below the MDA and, at a speed of 130 knots, struck the ground and crashed in a field located 4 km short of runway 06. The aircraft was totally destroyed. Eight passengers were rescued while 23 other occupants were killed, among them the Brazilian politician Ildefonço Cardeiro.
Probable cause:
The exact cause of the accident could not be determined with certainty. However, it is believed that the accident was the consequence of a controlled flight into terrain after the crew continued the approach in poor weather conditions and descended below the MDA until the aircraft, in a flaps and gear down configuration, impacted ground. The following contributing factors were identified:
- A difference of 70 feet in the settings was noted between both pilot's altimeters,
- Poor crew coordination,
- Complacency on part of the flying crew caused several deviations from procedures during the approach,
- Lack of crew resources management,
- The crew failed to check the altitude during the final stage of the approach,
- Poor weather conditions.
Final Report:

Ground accident of an Embraer EMB-120RT Brasília in Manaus

Date & Time: Aug 13, 2002 at 1225 LT
Type of aircraft:
Operator:
Registration:
PT-WGE
Flight Phase:
Survivors:
Yes
Schedule:
Humaitá – Manaus
MSN:
120-004
YOM:
1986
Flight number:
RLE4847
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13474
Captain / Total hours on type:
518.00
Copilot / Total flying hours:
4110
Copilot / Total hours on type:
3660
Aircraft flight hours:
26756
Circumstances:
Following an uneventful flight from Humaitá, the crew completed the landing at Manaus-Eduardo Gomes Airport. After taxi, the crew was approaching the apron when he feathered the propellers and applied the brakes as they wanted to stop the aircraft. There was no deceleration despite both crew applied brakes. The copilot suggested to use reverse thrust but this was not possible as the propellers were already feathered. Out of control, the aircraft struck a brick building, damaging the left engine, and the right landing gear fell into a drainage ditch, approximately one meter deep. All 25 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- The crew did not have sufficient training to enable the desired assertiveness for the correct use of aircraft resources, which would probably have prevented the accident, since, instead of applying the emergency brake, they applied reverse with the feathered props, contrary to the procedure provided for in the Aircraft Manual.
- The maintenance services were not efficient, as they did not comply with the Aircraft Maintenance Manual in relation to the dimensional adjustment of the Hub Cap Drive Clips' drive clips, and the Service Bulletin incorporated stickers to the outer doors of the main landing gear, as a reminder to the mechanic to check the clearances.
- The copilot failed to apply the reverse pitch on the propellers as they were feathered, and at that moment the emergency brake should be commanded to brake the aircraft.
- The company failed to adequately check the execution of the actions provided for in the Aircraft Maintenance Manual regarding the 'Antiskid' system and to verify the application of all service bulletins issued by the manufacturer.
Final Report: