Crash of a Cessna 560XLS Citation Excel in Santos: 7 killed

Date & Time: Aug 13, 2014 at 1000 LT
Operator:
Registration:
PR-AFA
Survivors:
No
Schedule:
Rio de Janeiro – Santos
MSN:
560-6066
YOM:
2011
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
On approach to Santos Air Base, State of São Paulo, crew abandoned the approach and started a go around when he lost control of the aircraft that plunged into the earth and crashed in flames in a near vertical position, some 4,3 km short of runway. All seven occupants were killed, among them the Brazilian politician Eduardo Campos who was travelling to Santos as part of the presidential campaign. The candidate was accompanied by his chief of cabinet, a journalist, his chauffeur and an official photographer. This is the first fatal accident involving a Cessna 560XL Citation Excel since its arrival on the market in 1996. Built in 2011, the aircraft was a 560XLS version owned by the Grupo Andrade (AF Andrade Empreendimentos e Participaçoes). In a first statement dated three days after the accident, investigators confirmed that the Cockpit Voice Recorder was readable but the data contained concerned a preceding flight. Therefore, no data about the accident could not be recorded.
Probable cause:
It was determined that the loss of control on final approach was caused by a spatial disorientation on part of the captain who was not sufficiently trained on this type of aircraft. Losing situational awareness, the pilot adopted a wrong approach configuration with full power that led the aircraft to pitch down up to 70°. In such condition, the aircraft was uncontrollable. Overconfidence on part of the captain and negligence of the approach procedures contributed to this situation, as well as fatigue and low visibility caused by marginal weather conditions. No technical anomalies were noted on the aircraft, except the fact that the CVR was deactivated during this flight for undetermined reason.

Crash of a Cessna C-98A in Bom Jardim da Serra: 8 killed

Date & Time: Aug 2, 2011 at 1327 LT
Type of aircraft:
Operator:
Registration:
2735
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Porto Alegre - Rio de Janeiro
MSN:
208-2130
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
Aircraft was on its way from Porto Alegre-Canoas Air Base to Rio de Janeiro-Galeao Airport. While overflying State of Santa Catarina in poor weather conditions, the single engine aircraft hit a mountain slope and was destroyed by impact forces and post impact fire. All eight occupants assigned to the 5th Air Transport Squadron were killed.

Crash of a Learjet 55 Longhorn in Rio de Janeiro

Date & Time: Aug 12, 2010 at 0916 LT
Type of aircraft:
Operator:
Registration:
PT-LXO
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro-Rio de Janeiro
MSN:
55C-135
YOM:
1988
Country:
Crew on board:
3
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crew was performing a positionning flight from Santos Dumont to Antonio Carlos Jobim Airport. After departure from Santos Dumont, pilots informed ATC about technical problems and elected to return. After touch down, aircraft overrun runway and came to rest in Guanabara Bay. All three occupants survived while the aircraft was damaged beyond repair.
Probable cause:

Crash of an Airbus A330 in 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:
En route, while cruising at 35,000 feet north of Fernando de Noronha island located 365 km northeast from Brazilian coast, the aircraft encountered bad weather conditions. In a time laps of 45 minutes, the aircraft probably encountered simultaneously strong turbulences, ice and lightning. First, it seems that the autopilot failed (volontaraly or not), some navigation instruments also failed and eventually, the vertical cabin pressure failed. The crew lost control and the aircraft dove into the sea. It is not known yet if the aircraft desintegrated during descent or at impact. All 228 occupants were killed. To date, this crash is the most terrible in Air France history.
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 destabilisation 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 behavioural hypotheses in classifying the loss of airspeed information as “major” were not validated in the context of this accident. Confirmation of this classification thus F-GZCP 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, signalled 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 behaviour 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:ˆ 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;ˆ 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;ˆ The late identification by the PNF of the deviation from the flight path and the insufficient correction applied by the PF;ˆ The crew not identifying the approach to stall, their lack of immediate response and the exit from the flight envelope;ˆ 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:ˆ The feedback mechanisms on the part of all those involved that made it impossible: y 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”; ˆ Task-sharing that was weakened by: y Incomprehension of the situation when the autopilot disconnection occurred, y Poor management of the startle effect that generated a highly charged emotional factor for the two copilots; ˆ The lack of a clear display in the cockpit of the airspeed inconsistencies identified by the computers; ˆ The crew not taking into account the stall warning, which could have been due to: y A failure to identify the aural warning, due to low exposure time in training to stall phenomena, stall warnings and buffet, by The appearance at the beginning of the event of transient warnings that could be considered as spurious, y The absence of any visual information to confirm the approach-to-stall after the loss of the limit speeds, y 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, y 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 Learjet 35 in Sao Paulo: 8 killed

Date & Time: Nov 4, 2007 at 1409 LT
Type of aircraft:
Operator:
Registration:
PT-OVC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Sao Paulo-Rio de Janeiro
MSN:
35A-399
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The crew was returning to Rio de Janeiro after an ambulance flight to Sao Paulo-Campo de Marte airport. Less than one minute after takeoff from runway 30, the aircraft banked right and crashed on several houses located along Bernardino de Sena street. Both pilots and also 6 people on ground were killed.

Crash of a Boeing 737-800 in Peixoto de Azevedo: 154 killed

Date & Time: Sep 29, 2006 at 1657 LT
Type of aircraft:
Operator:
Registration:
PR-GTD
Flight Phase:
Survivors:
No
Site:
Schedule:
Manaus - Brasilia - Rio de Janeiro
MSN:
34653
YOM:
2006
Flight number:
GLO1907
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
148
Pax fatalities:
Other fatalities:
Total fatalities:
154
Aircraft flight hours:
202
Aircraft flight cycles:
162
Circumstances:
Flight GLO1907 left Manaus-Eduardo Gomes airport at 1535LT for Rio de Janeiro with an intermediate stop at Brasilia. While cruising at 37,000 feet, the aircraft collided with an Embraer Legacy 600. Registered N600XL, it was flying to the US with 4 pax and a crew of 2 on board. The left winglet detached from the Legacy which could land safely at Novo Progresso-Cachimbo Air Base without further incident. The Boeing 737-800 crashed in a vertical position in a wooded area located 30 km from Peixoto de Azevedo, in the State of Mato Grosso. Search & Rescue found debris on 30SEP2006 in the morning in an isolated area. Nobody survived among 154 occupants. The Boeing 737, brand new, totalized 202 flying hours only.
Probable cause:
It appeared that the collision was caused by an ATC error and also some mistakes done by the Legacy's crew.

Crash of a Let 410 in Saquarema: 19 killed

Date & Time: Mar 31, 2006 at 1739 LT
Type of aircraft:
Operator:
Registration:
PT-FSE
Flight Phase:
Survivors:
No
Site:
Schedule:
Macaé-Rio de Janeiro
MSN:
91 25 32
YOM:
1991
Flight number:
TIM6865
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
10000
Captain / Total hours on type:
39.00
Copilot / Total flying hours:
5220
Copilot / Total hours on type:
1719
Aircraft flight hours:
2739
Aircraft flight cycles:
3960
Circumstances:
The aircraft left Macaé regional Airport at 1719LT and crashed near Saquarema at 1735LT. ETA was scheduled at Rio at 1802LT. Rescue teams did not found any survivors among the 19 occupants. It is the first accident involving a Let 410 in Brazil. TEAM = Transportes Especiais Aéreos e Malotes

Crash of a Cessna 525 CJ1 in Rio de Janeiro: 2 killed

Date & Time: Sep 15, 2005 at 1455 LT
Type of aircraft:
Operator:
Registration:
PT-WLX
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Rio de Janeiro-Rio de Janeiro
MSN:
525-0176
YOM:
1997
Country:
Crew on board:
2
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was making a positionning flight from Santos Dumont airport to Jacarepagua. The aircraft crashed in a wooded area located near Alto da Boa Vista, few minutes after takeoff. Both pilots were killed.

Crash of a Mitsubishi MU-300 Diamond in Santos

Date & Time: Mar 23, 2003 at 1200 LT
Type of aircraft:
Registration:
PT-LNN
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro-Santos
MSN:
0048
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On landing, the aircraft suffered aquaplaning. It overran the wet runway and came to rest in a ditch.