Technical failure

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.

The Interstate Aviation Committee (MAK) released their final report in Russian concluding the probable causes of the accident were:
The catastrophe of the AN-24 RA-47302 occurred when ditching became necessary due to a fire in the left hand engine's nacelle. The destruction of the aircraft and loss of life was caused by collision with underwater obstacles that the crew could not anticipate or avoid. The fire in the left hand engine nacelle was caused by the fracture of a centrifugal breather releasing an air-fuel emulsion into the engine compartment as well as a delayed reaction to shut the engine down by the crew following an magnetic chip detector indication together with indications of oil pressure fluctuations, a burning smell and a low oil pressure indication. A delay in indicating engine vibrations to the crew as result of degradation of the engine vibration sensoring equipment, most likely caused by changes of the rotor speed of the engine as result of the aft bearing failure of the compressor rotor and/or misalignment of the sensor, which probably influenced the decision of the crew to shut the engine down with a delay. Cause of the fracture of the centrifugal breather was the destruction of the impeller due to prolonged exposure to hot air-fuel emulsion due to the failure of the aft compressor rotor support bearing. It was not possible to determine the cause of the destruction of the aft compressor rotor support bearing due to significant secondary damage. Most likely the destruction was caused by misalignment such as:
- Incorrect assembly of support parts mating with the compressor rotor during on-condition engine repairs,
- Or deviations from required geometry of support parts mating with the compressor rotor.
Contributing factors were:
- Psychological unpreparedness of the captain to shut the engine down due to lack of experience with the aircraft on one engine inoperative
- Late detection of the fire and as a consequence late attempts to extinguish the fire, it was however not possible to establish why the fire was detected late due to lack of objective information about the performance of the fire alarm systems.

During a flight of transport of values, in the phase of cruise, a smoke emergency appeared in the cockpit, that when not being able to be controlled, derived in a landing of emergency by precaution in a nonprepared field, which resulted without apparent damages to the aircraft, triggering later a fire and the almost total destruction of the same, due, very probably, to an electrical failure that originated the fire.

The right engine caught fire in flight for unknown reasons.

The NTSB determines that the probable cause of this accident was the failure of a midspar fitting, which was susceptible to fatigue cracking and should have been replaced with a newer, more fatigue-resistant version of the fitting as required by an airworthiness directive. Also causal was an erroneous maintenance entry made by a previous aircraft owner, which incorrectly reflected that the newer fitting had been installed.

The pilot experienced symptoms of symmetrical power loss sufficient to prevent the aircraft from sustaining level flight and made a forced landing into a field. The deficiency in the aircraft’s takeoff performance suggested that its powerplants were not producing sufficient thrust. As fuel contamination was discounted and no fault was found in either engine, it was concluded that, in all probability, the poor performance was not caused by a failure in either powerplant. Maximum rpm was not selected for departure but it was unlikely that this explained the aircraft’s poor performance on the runway or in the air. The pilot insisted that he had set torque to the takeoff limit. There was insufficient evidence to enable the cause of the apparent power loss to be determined.

Engine failure in flight for undetermined reasons.