Crash of a Learjet 31A in Diamantina

Date & Time: Jan 2, 2021 at 0851 LT
Type of aircraft:
Operator:
Registration:
PP-BBV
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Diamantina
MSN:
31-113
YOM:
1995
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4606
Captain / Total hours on type:
1138.00
Copilot / Total flying hours:
1475
Copilot / Total hours on type:
680
Circumstances:
The airplane departed São Paulo-Congonhas Airport on an ambulance flight to Diamantina-Juscelino Kubitschek Airport, carrying two doctors and two pilots. Following an unstabilized approach, the airplane landed too far down the runway 03 and was unable to stop within the remaining distance. It overran, went down a ravine and came to rest. All four occupants evacuated with minor injuries while the aircraft was damaged beyond repair.
Probable cause:
Following a wrong approach configuration on part of the crew, it was determined that the airplane landed about 600 metres from the runway end. In such conditions, the airplane could not be stopped within the remaining distance.
The following contributing factors were identified:
- Both pilots knew each other well and often flew together, thus it is possible that they over-relied on each other during the final phase of the flight,
- This over-confidence led the crew to neglect certain parameters related to the approach manoeuvre,
- Lack of crew coordination,
- Post-accident medical examinations revealed that the pilot-in-commands' (PF) lack of reaction to the pilot monitoring's (PM) warnings, and his impaired alertness, could indicate that he was suffering from the effects of alcohol and fatigue, reducing his performances,
- The pilots' decision to continue with the landing procedure despite an unstabilized approach characterized by inadequate situational awareness,
- Poor judgment on the part of the crew who failed to take the correct decision to initiate a go-around procedure.
Final Report:

Crash of a Embraer EMB-500 Phenom 100 in São Pedro

Date & Time: Oct 30, 2020 at 1750 LT
Type of aircraft:
Operator:
Registration:
PR-LMP
Survivors:
Yes
Schedule:
São Paulo – São Pedro
MSN:
500-00094
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7300
Captain / Total hours on type:
2350.00
Copilot / Total flying hours:
676
Copilot / Total hours on type:
409
Circumstances:
After touchdown on runway 29 at São Pedro Airport, the crew initiated the breaking procedure but the airplane failed to stop within the remaining distance. It overran, collided with various obstacles, went down an embankment of 10 metres and eventually came to rest 130 metres further, bursting into flames. All four occupants evacuated safely and the airplane was destroyed by a post crash fire.
Probable cause:
Studies and research showed that the low deceleration of the aircraft and the limitation of the hydraulic pressure provided by the brake system were compatible with a slippery runway scenario. Thus, one inferred that the runway was contaminated, a condition that would reduce its coefficient of friction and impair the aircraft's braking performance, making it impossible to stop within the runway limits. On account of the mirroring condition of the runway in SSDK, it is possible that the crew had some difficulty perceiving, analyzing, choosing alternatives, and acting appropriately, given a possible inadequate judgment of the aircraft's landing performance on contaminated runways.
Final Report:

Crash of a BAe 125-800B in São Paulo

Date & Time: Feb 9, 2017 at 2211 LT
Type of aircraft:
Operator:
Registration:
PT-OTC
Survivors:
Yes
Schedule:
Brasília – São Paulo
MSN:
258194
YOM:
1991
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane departed Brasilía-Presidente Juscelino Kubitschek Airport in the evening on a charter flight to São Paulo-Congonhas, carrying two pilots and one passenger, the Senator Aécio Neves da Cunha. During the takeoff roll, a tire on one of the main landing gear failed. The crew continued the flight, informed ATC about his situation and preferred to divert to São Paulo-Guarulhos Airport that offered longer runway for an emergency landing. After touchdown by night, the aircraft deviated to the right then veered off runway. The left main gear collapsed and the aircraft came to rest in a grassy area. All three occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Cessna 650 Citation VII in Guarda-Mor: 4 killed

Date & Time: Nov 10, 2015 at 1904 LT
Type of aircraft:
Operator:
Registration:
PT-WQH
Flight Phase:
Survivors:
No
Schedule:
Brasília – São Paulo
MSN:
650-7083
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
13143
Copilot / Total flying hours:
2527
Copilot / Total hours on type:
1633
Circumstances:
The aircraft took off from the Presidente Juscelino Kubitschek (SBBR) Aerodrome, Brasília - DF, to the Congonhas Aerodrome (SBSP), São Paulo - SP, at 2039 (UTC), to carry out a personnel transportation flight with two crewmembers and two passengers on board. During the cockpit preparation procedure, the crew members commented about the operation of the Pitch Trim System. The first flight of the day, that occurred in the morning, was from São Paulo to Brasilia and with no abnormalities. About thirty minutes after take-off from Brasília, still during the climb, near the FL370, the cabin voice recorder recorded a characteristic sound of the aircraft’s horizontal stabilizer moving. Then, the aircraft made a downward trajectory with high speed and a big rate of descent until the impact against the ground. The aircraft was destroyed. All occupants perished at the site, among them Lúcio Flávio de Oliveira and Marco Antonio Rossi, two Directors of Banco Brasdesco.
Probable cause:
Contributing factors:
- Control skills – undetermined
It is possible that, after inadvertent movement of the horizontal stabilizer, the crewmembers did not operate on the control switches of the secondary pitch trim system, since no other warning sound (Clacker) was recorded on the CVR recordings. The action prevised in the emergency procedures Pitch Trim Runaway or Failure, item 3, regarding trimming of the aircraft through the secondary system, possibly, was not performed. The performance of the crew may have been restricted only to the elevator control on the aircraft controls or to the control of the stabilizer associated with the primary trimming mode.
- Attitude – undetermined
The decision to make the flight without the proper functioning of the primary pitch trim and autopilot system may have been the result of the pilot's self-confidence because of the successful previous flight under similar operating conditions. Considering the hypothesis that the updated Shutdown Checklist, which should incorporate the Stabilizer Trim Backdrive Monitor - TEST, was not performed after the precrash flight, one could consider that there was a lack of adhesion to the aircraft operating procedures. Such an attitude could be associated with the pilot's self-confidence about the aircraft's operating routine, whose acquired experience could have given him the habit of ignoring some of the procedures deemed less important during the flight completion phase.
- Crew Resource Management – a contributor
Throughout the flight, there was an absence of verbalization and communication of the actions on the checklist. Similarly, in the face of the emergency situation of the horizontal stabilizer (Pitch Trim Runaway or Failure), no statements were identified regarding the actions required to manage this situation among the crew. These characteristics denote inefficiency in the use of human resources available for the aircraft operation.
- Training – undetermined
It is possible that the absence of a periodic training in simulator, especially the emergency Pitch Trim Runway or Failure, has affected the performance of the crew, as far as the CVR did not record statements related to the actions required by the abnormal condition experienced.
- Organizational culture – undetermined
The operator did not usually properly fill out the PT-WQH flight logbook. This condition evidenced the existence of informal rules regarding the monitoring of the operational conditions of the aircraft. In this context, it is possible that the history of failures related to the pitch trim system has not been registered.
- Piloting judgment – undetermined
Moments prior to takeoff, it was recorded in the CVR speeches related to the flight without the autopilot, possibly related to a failure or inoperativeness of the primary pitch trim system. The takeoff with a possible failure in the pitch trim system of the aircraft, showed an inadequate assessment of the risks involved in the operation under those conditions.
- Aircraft maintenance – undetermined
It was not possible to establish a link between the maintenance services performed on the aircraft in September 2015 and the events that resulted in the accident occurred on 10NOV2015. However, it was not ruled out that an incomplete crash survey was carried out in the pitch trim system of the aircraft, due to the lack of detail of the service orders.
- Decision-making process – a contributor
The sounds related to the test positions of the Rotary Test Switch have not been recorded in the CVR recording, so it is possible to conclude that the Warning Systems - Check item of the Cockpit Preparation Checklist has not been performed. The decision to perform the flight without the complete execution of all items of the Cockpit Preparation Checklist, prevented the correct verification of the primary longitudinal Trim system of the aircraft and reflected an inadequate judgment about the risks involved in that operation.
- Interpersonal relationship – undetermined
According to the CVR data, there was a possible rush of the crew to take-off, even though it was verified that the aircraft's pitch trim system did not work properly. It was not possible to determine if this rush was motivated by passengers’ pressure or self-imposed by the pilot.
- Support systems – undetermined
It is possible that the Pilots' Abbreviated Checklist - NORMAL PROCEDURES, aboard the aircraft, was outdated, without the incorporation of the Stabilizer Trim Backdrive Monitor - TEST procedure in the Shutdown Checklist. The possible completion of Shutdown Checklist with outdated procedures would have hampered the manufacturer's suggested verification for identification of abnormalities in the aircraft's pitch trim system.
- Managerial oversight – undetermined
The records and control of the operational check flights, both by the maintenance shop and by the operator, prevised in documentation issued by the manufacturer (SB650- 27-53 and ASL650-55-04) were not performed in an adequate manner, indicating possible weaknesses in the supervision of the maintenance activities.
Final Report:

Crash of a Cessna 525B Citation CJ3 in São Paulo

Date & Time: Nov 11, 2012 at 1721 LT
Type of aircraft:
Operator:
Registration:
PR-MRG
Survivors:
Yes
Schedule:
Florianópolis – São Paulo
MSN:
525B-0187
YOM:
2008
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4048
Captain / Total hours on type:
521.00
Copilot / Total flying hours:
648
Copilot / Total hours on type:
189
Circumstances:
Following an uneventful flight from Florianópolis, the crew started the approach to São Paulo-Congonhas Airport Runway 35R. After touchdown, the airplane was unable to stop within the remaining distance. It overran, went down an embankment and came to rest against a fence, broken in two. The passenger and the copilot were slightly injured and captain was seriously injured. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- The commander was overconfident in himself and the aircraft which led him to lose the critical capacity to discern the risks involved in the procedure that was adopting. Corroborating was the fact that the pilot judged he had much knowledge in this operation and knew exactly how the aircraft responded. It can be inferred there was complacency by the copilot on the actions of the commander, during the approach at high speed, because even feeling uncomfortable, he did not make an incisive interference because he believed in the idea that the commander had done this kind of approach, with high speed, and so knowing what he was doing.
- The pilot failed to identify the location of touch down during landing and not knowing how much runway was remaining, he decided he should not rush, thus demonstrating low situational awareness and lack of awareness, impacting the proper reaction time for the situation (Rush), which was not performed , leading the occurrence in question.
- The crew failed to properly assess the information available like speed and the runway length for the realization of a safe landing, which led to a poor judgment of the situation at hand, making the decision not to adopt the missed approach procedure.
- The distance between the crew, caused unconsciously by the commander's position with excess knowledge in the operation and the aircraft, and the insecurity of the copilot in considering new and inexperienced, resulted in a lack of assertiveness of the copilot to inform, with little emphasis, the commander of his perception of excessive airspeed.
- The crew did not adopt good crew resource management, failing to communicate with assertiveness and share critical information in time prior to landing, allowing the speeding remained present until the touchdown.
- Despite having adequate experience and training, the commander did not use the resources available, such as speed brakes to reduce the aircraft approach speed.
- The variable wind direction and predominantly tail intensity equal to or greater than 10 knots, allowed excessive speed during landing.
- The crew did not adopt good crew resource management, allowing the high speed to remain present until the touchdown.
- The commander thought he would be able to perform the approach and landing with the speed above the expected.
Final Report:

Crash of a Beechcraft F90 King Air off Belém

Date & Time: Feb 8, 2012 at 2244 LT
Type of aircraft:
Operator:
Registration:
PT-OFD
Survivors:
Yes
Schedule:
São Paulo – Belém
MSN:
LA-118
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5500
Captain / Total hours on type:
70.00
Copilot / Total flying hours:
6750
Copilot / Total hours on type:
7
Circumstances:
The aircraft departed São Paulo-Congonhas Airport at 1630LT on a flight to Belém, carrying two passengers and two pilots. During the approach to Belém-Val de Cans-Júlio Cezar Ribeiro Airport runway 06 by night, one of the engine flamed out. Few seconds later, the second engine failed as well. The crew ditched the aircraft in the Bay of Guajará, about 1,2 km short of runway 06 threshold. All four occupants were rescued by servicemen of the Naval Base who were on duty at the time of the accident. A pilot was slightly injured while three other occupants escaped uninjured. The aircraft sank and the wreckage was recovered 12 days later.
Probable cause:
The following findings were identified:
a) The pilots had valid aeronautical medical certificates;
b) The pilots had valid technical qualification certificates;
c) The aircraft captain had qualification and enough experience for the flight in question;
d) The copilot was under training;
e) The aircraft had a valid airworthiness certificate;
f) The planning of the flight from SBSP to SBBE was done by the pilot in command, who took in consideration an aircraft with a full load of fuel;
g) The flight plan read that the fuel endurance was 7 hours and 30 minutes of flight, for an estimated elapse time of 5 hours and 40 minutes at FL230;
h) When the aircraft was passing over the city of Palmas, State of Tocantins, the pilots decided, in conjunction, to proceed non-stop to the destination, discarding the need to make an intermediate landing for refueling;
i) The aircraft was registered in the passenger transport category (TPP) and was engaged in the transport of a sick person;
j) The fuel quantity indicators and the fuel flow indicators of the aircraft were not showing dependable information;
k) The flight plan for the leg betwren SBSP and SBBE contained information of sick person transportation, but there was no sick person on board;
l) The aircraft made a ditching near the banks of Guajará Bay, at a distance of approximately 1,200 meters from the threshold of runway 06 of SBBE;
m) The passengers and crew were rescued by Brazilian Navy servicemen on duty on the Naval Base of Val de Cans;
n) One of the pilots and both passengers got out uninjured, while the other pilot suffered minor injuries; and
o) The aircraft sustained substantial damage.
Contributing factors:
Concerning the operation of the aircraft
a) Attitude – a contributor
The captain failed to comply with norms and procedures by accepting to fly an aircraft on his day of rest, even knowing that he was to start his on-call duty hours as soon as he landed in SBBE.
He also showed to be overconfident when he decided to fly directly from SBSP to SBBE, trusting the 7-hour fuel endurance of his aircraft and the fuel consumption information displayed by the instruments, even after identifying their malfunction. The pilot under training, in turn, was complacent by accepting and agreeing with the pilot-in-command’s decision, without questioning his calculations or motivations for flying direct to the destination.
b) Motivation – a contributor
The captain was eager to return to SBBE on that same day, because he was supposed to start his on-call duty hours in the air taxi company for which he worked.
c) Decision-making process – a contributor
The captain failed to comply with important aspects concerning the route conditions and aircraft instruments by making a decision to fly directly from SBSP to SBBE.
Psychosocial information
a) Communication – a contributor
There was lack of assertiveness on the part of the copilot since he did not question the captain’s calculations and/or motivations to fly non-stop, when he (the copilot) considered that making a stop for refueling would be safer.
b) External influence – a contributor
The involvement of the captain with activities of another company on that same day, in addition to events belonging to his private life, had influence on his decisions in the initial planning of the flight and during the flight en route.
Organizational information
a) Work organization – a contributor
The company delegated responsibility for the entire planning of the flight to the pilots. Therefore, there was not any interference on the part of the company in the crew’s work day and in the legs defined for the flight.
b) Organizational culture – a contributor
The fact that the company performed an operation for which it was not certified reflected the fragility of an organizational culture which allowed it to perform activities unfavorable to operational safety.
Operational Factor
Concerning the operation of the aircraft
a) Flight indiscipline – a contributor
On several occasions during the flight, the pilots failed to comply with the norms and regulations in force, such as the sections 91.167 and 91.205 of the RBHA 91, the Pilot Operating Handbook and FAA Approved Airplane Flight Manual, and the Lei do Aeronauta (Law of the Aeronaut, Law nº 7.183 of 5 April 1984).
b) Training – undetermined
Before the ditching, the pilot unlocked the rear door of the aircraft and, then, failed to instruct the passengers as to the opening of the emergency exit. This fact shows a probable deviation in the process of training previously received by the captain, since the procedure prescribed for the situation was to abandon the aircraft through the emergency exit, which had to be unlocked after the ditching.
c) Piloting judgment – a contributor
At the moment of their decision to proceed non-stop to the destination, there was an inappropriate evaluation on the part of the crew, because they did not consider the hourly consumption until that point, and the malfunction of the fuel capacity indicator did not allow them to know the exact amount of fuel remaining in the tanks.
d) Flight planning – a contributor
There was a mistake on the part of the captain relative to the planning of the flight, since, in addition to a total flight time of 5 hours and 40 minutes, he did not consider the fuel necessary to fly to an alternate airport plus 45 minutes of flight. The captain and the pilot under training made an inappropriate evaluation of the effects brought by the operational conditions along the flight route.
Final Report:

Crash of a Beechcraft 350 Super King Air in Porto Seguro: 14 killed

Date & Time: May 22, 2009 at 2053 LT
Registration:
PR-MOZ
Flight Type:
Survivors:
No
Schedule:
São Paulo – Porto Seguro
MSN:
FL-237
YOM:
1999
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
20000
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
357
Copilot / Total hours on type:
107
Circumstances:
The twin engine aircraft departed São Paulo-Congonhas Airport at 1831LT on a private flight to Porto Seguro, carrying 12 passengers and two pilots, among them the Brazilian Businessman Roger Wright, his wife, children and grandchildren. On approach to Porto Seguro-Terravista Golf Club Airport, the crew encountered poor weather conditions and the visibility was low due to the night. On final approach to runway 15, the aircraft impacted trees located 900 metres from the runway threshold. The aircraft continued for about 700 metres then struck others trees and crashed 200 metres short of runway, bursting into flames. The aircraft was totally destroyed and all 14 occupants were killed.
Probable cause:
The crew's decision to continue the approach in poor weather conditions following a high motivation to land at destination.
The following contributing factors were identified:
- The crew failed to follow the published procedures,
- The crew did not take the bad weather conditions into consideration and took the decision to land,
- Limited visibility due to rain falls and night,
- Weather conditions affected the perception of the pilots who suffered a loss of situational awareness,
- Poor judgment of the situation and flight conditions on part of the crew,
- The crew continued the approach under VFR mode in IMC conditions,
- The crew carried out an improvised VFR approach via a GPS system,
- Excessive approach speed,
- Poor crew coordination,
- Lack of crew discipline.
Final Report:

Crash of a Beechcraft BeechJet 400A in São José dos Campos

Date & Time: Jul 15, 2008 at 1130 LT
Type of aircraft:
Operator:
Registration:
PT-WHF
Flight Type:
Survivors:
Yes
Schedule:
São Paulo - São José dos Campos
MSN:
RK-82
YOM:
1994
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4300
Captain / Total hours on type:
2811.00
Copilot / Total flying hours:
540
Copilot / Total hours on type:
35
Circumstances:
The crew departed São Paulo-Congonhas Airport on a positioning flight to São José dos Campos. While descending to São José dos Campos, the captain led the controls to the copilot who was still under instruction. On final, the aircraft was too high on the glide. The captain took over controls but his reaction was excessive. The aircraft suddenly rolled to the right, causing the right wing to struck the ground few dozen metres short of runway 15 threshold. The aircraft landed and came to rest on the main runway. Both pilots evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The captain did not conduct a preflight briefing and then improvised during the descent by deciding to leave the controls to the copilot while he was still under instruction.
The following contributing factors were identified:
- The copilot who was pilot-in-command on final was in his initial training process,
- The captain authorized the copilot to be the PIC while he was still under initial training,
- The captain was not qualified to operate as an instructor,
- The captain did not make any simulator training for more than two years,
- The copilot had never completed any simulator training since the beginning of his training,
- Lack of crew coordination,
- Poor judgment on part of the captain.
Final Report:

Crash of an Airbus A320-233 in São Paulo: 199 killed

Date & Time: Jul 17, 2007 at 1854 LT
Type of aircraft:
Operator:
Registration:
PR-MBK
Survivors:
No
Site:
Schedule:
Porto Alegre – São Paulo
MSN:
789
YOM:
1998
Flight number:
JJ3054
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
181
Pax fatalities:
Other fatalities:
Total fatalities:
199
Captain / Total flying hours:
13654
Captain / Total hours on type:
2236.00
Copilot / Total flying hours:
14760
Copilot / Total hours on type:
237
Aircraft flight hours:
20000
Aircraft flight cycles:
9300
Circumstances:
On 17 July 2007, at 17:19 local time (20:19 UTC), the Airbus aircraft, model A320, registration PR-MBK, operating as flight JJ3054, departed from Porto Alegre (SBPA) destined to Congonhas Airport (SBSP) in São Paulo city, São Paulo State. There were a total of 187 souls on board the aircraft, being six active crew members and 181 passengers, including 2 infants and 5 extra crew members (not on duty). The weather prevailing along the route and at the destination was adverse, and the crew had to make a few deviations. Up to the moment of the landing, the flight occurred within the expected routine. The aircraft was operating with the number 2 engine reverser de-activated, in accordance with the Minimum Equipment List (MEL). According to information provided to the TWR by crews that had landed earlier, the active runway at Congonhas (35L) was wet and slippery. During the landing, at 18:54 local time (21:54 UTC), the crew noticed that the ground spoilers had not deflected, and the aircraft, which was not slowing down as expected, veered to the left, overran the left edge of the runway near the departure end, crossed over the Washington Luís Avenue, and collided with a building in which the cargo express service of the very operator (TAM Express) functioned, and with a fuel service station. All the persons on board perished. The accident also caused 12 fatalities on the ground among the people that were in the TAM Express building. The aircraft was completely destroyed as a result of the impact and of the raging fire, which lasted for several hours. The accident caused severe damage to the convenience shop area of the service station and to some vehicles that were parked there. The TAM Express building sustained structural damages that determined its demolition. The aircraft was completely destroyed.
Probable cause:
Human factors
1.1 Medical aspect
a. Pain - Undetermined
At a certain moment, during the approach, the PIC reported having a mild headache. Although it was not possible to verify which type of headache it was, or even to evaluate its intensity, it is possible that this trouble may have influenced his cognitive and psychomotor capabilities during the final moments of the flight, when the unpredictability of the situation demanded a higher effectiveness of performance. This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.

1.2 Operational aspect
a. Training - A contributor
The theoretical qualification of their pilots was founded on the exclusive use of computer interactive courses (CBT), which allowed a massive training, but did not ensure the quality of the training received. In addition, the formation of the SIC was restricted to the “Right Seat Certification”, something that proved insufficient for him to deal with the critical situation experienced after the landing. Lastly, there was a perception among the crews interviewed that the training through the years and on account of the high demand resulting from the company’s growth was being abbreviated.

b. Application of the commands - Undetermined
One of the hypotheses considered in this investigation was that the pilot may have attempted to perform a procedure no longer in force at the time of the accident for the landing with a pinned reverser. This procedure consisted in the receding of both levers to the “IDLE” position during the flare at about a 10-foot altitude, and, after touching down, in activating the only reverser available, maintaining the thrust lever of the other engine in the “IDLE” position.
This procedure, though being more efficient from a braking perspective, could induce the crew to making mistakes, as there were several reports of occurrences in which there was a wrong setting of the levers, motivating the manufacturer to establish a new procedure, months before the accident. Thus, there is a high probability that the PIC inadvertently left one of the thrust levers in the “CL” position, placing the other one first in “IDLE” and later in the “REV” position. This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.

c. Cockpit coordination - A contributor
Independently of the hypothesis considered, the monitoring of the flight at the landing was not appropriate, since the crew did not have perception of what was happening in the moments that preceded the impact. This loss of situational awareness hindered the adoption of an efficient and timely corrective action.

d. Forgetfulness by the pilot - Undetermined
It is possible that the pilot has inadvertently left one of the levers at the “CL” position, while trying to perform a procedure no longer in force for the operation with a pinned reverser. This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.

e. Flight indiscipline - Undetermined
The procedure prescribed for the operation with a pinned reverser had been modified by the manufacturer and, according to the FDR recordings, the procedure in force was known to the crew and executed by them on the leg that preceded the accident. However, as this procedure imposed an increase of up to 55 meters in the calculations of runway distance required for landing, it is possible that the PIC deliberately tried to perform adoption of a procedure no longer in force would characterize flight indiscipline. This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.

f. Influence from the environment - Undetermined
The operating conditions of the Congonhas runway, may have affected the crew’s performance from a psychological perspective, considering the state of anxiety that was present in the cockpit.
In addition, the lack of luminosity resulting from the operation at night time, associated with the size and color of the thrust levers may have hindered the verification of a contingent inappropriate positioning of those controls during the landing. This factor was considered undetermined due to the impossibility of confirming, in factual terms, the psychological influence of the runway operating conditions and/or lack of luminosity on the performance of the crew.

g. Judgment of pilotage - Undetermined
In view of all the operation scenario - the 55 meters added on account of the reverser procedure, the 2.4 extra tons of fuel on account of the tankering, the crowded aircraft, the pressure to proceed to Congonhas, the PIC’s physiological condition (headache), a SIC with little experience in the A-320 and in its autothrust system, the wet and slippery runway, the occurrences of the preceding days - there is a high probability that the PIC deliberately tried to perform the procedure no longer in force for the operation with a pinned reverser, in order to increase the braking efficiency, inadvertently leaving the number 2 engine thrust lever in the “CL” position. Considering this hypothesis, the diversion to an alternate airport would be desirable, instead of trying to perform a procedure that was not prescribed. This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.

h. Management planning - A contributor
At the time of the accident, the operator had a disproportional number of captains in comparison with the number of co-pilots, a fact that obliged the scheduling sector to form crews with 2 captains. Thus, although complying with the minimum requirements of the regulation in force, such a practice may have contributed to the creation of a climate of complacency in the cockpit of the JJ3054. Besides, the long experience of the SIC as a captain was not a guarantee of his competence in the co-pilot function - for which he had done only the “Right Seat Certification” training - and, added to his little experience in that aircraft, it contributed to the loss of situational awareness in the most critical moments of the flight.

i. Flight planning - Undetermined
Thus, considering the hypothesis that the PIC deliberately tried to perform the old procedure for a landing with a pinned reverser to increase the braking efficiency, it is possible that the use of that procedure was not appropriately prepared, something that could have favored the wrong positioning of the levers (according to the hypothesis mentioned above, it is possible that the PIC inadvertently left the nº2 engine thrust lever in the “CL” position.). The lack of a briefing for the descent in the CVR recording hindered the confirmation of a possible intention of applying the old procedure, no longer in force at the time. This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.

j. Little experience of the pilot - A contributor
Despite his long experience in commercial jets, the SIC possessed only about 200 flight hours in aircraft of the A320 type. Besides, his experience in the function of co-pilot was restricted to the “Right Seat Certification” training, which proved insufficient to deal with the emergency situation.

k. Management oversight - A contributor
The operator allowed the crew to be composed of two captains, with the occupant of the right-hand seat having done only the “Right Seat Certification” training. Besides, the lack of coordination between the several sectors of the company, especially between the sectors of operation and training, determined the lack of an appropriate monitoring of the processes and of the quality of the pilots’ professional formation.

Psychological aspect
a. Anxiety - Undetermined
The CVR recording allows to perceive that the PIC was showing anxiety in relation to the runway conditions for landing, and on two different occasions he asked the SIC to request from the TWR-SP the rain and runway conditions, and on one of them specifically, whether the runway was slippery. It is possible that the state of anxiety present in the PIC may have influenced the performance of the crew to some extent. This factor was considered undetermined due to the impossibility to confirm that this anxiety has effectively influenced the performance of the crew.

b. Perception error - A contributor
Although perceiving that the ground spoilers had not deflected, the pilots were not able to associate the non-deflection with the positioning of the thrust levers. In addition, there is a high probability that the pilots were led to believe that the lack of the expected deceleration after landing was a result of the conditions of operation with a wet runway, the influence of which, from a psychological aspect perspective in the field of individual variables, was perceived along the investigation.

c. Stress - Undetermined
The stress has effect on the cognitive level (diminution of the concentration, diminution of the response speed, degradation of the memory, etc.), emotional level (alteration of the characteristics of personality, weakening of the emotional control, lowering of the self-esteem, etc.), behavioral level (alterations of the sleep pattern, diminution of interests, verbal articulation problems, etc.), and physiological level (sudoresis, tachycardia, sleep pattern alterations, gastric and dermatologic symptoms, etc.). The presence of stress triggering stimuli was perceived, such as the state of anxiety on the part of the pilots, especially regarding the runway conditions, the cephalalgia of the PIC, the issues concerning the operation in Congonhas with a wet runway, the crowded aircraft and the inoperative reverser. However, it was not possible to determine whether those stimuli effectively led any of the two pilots to a high level of stress. This factor was considered undetermined due to the impossibility to confirm its contribution in factual terms.

d. Lack of perception - A contributor
Considering the hypothesis of a failure in the thrust control system, the contingent stimulus generated from the loss of resistance to the movement of the thrust levers may not have been perceived by the pilot(s), according to the CVR recordings. On the other hand, if one considers the hypothesis that the nº 2 engine thrust lever was inadvertently left in the “CL” position, while the pilots were trying to perform a procedure no longer in force, the characteristics of the autothrust system, which keep the levers motionless during the variations of thrust, in addition to the size and color of those control levers, hard to be observed on a night flight, were not sufficiently evident to be perceived by the pilots. This situation was aggravated by the lack of a warning device relative to the conflicting positioning of the thrust levers.

e. Loss of situational awareness - A contributor
Thus, no matter which hypothesis is considered, the loss of the situational awareness emerged as a result of the very lack of perception on the part of the pilots. In this sense, the automation of the aircraft, however complex, was not capable of providing the pilots with sufficiently clear and accurate stimuli, to the point of favoring their understanding of what was happening in the moments just after the landing in Congonhas.

f. Organizational climate - Undetermined
In relation to the crews of the company, the investigation identified the perception that there was a pressure on the part of the management against diversions, on account of the inconvenience they could arise for the passengers and for the company itself. If the pilots of the JJ3054 shared that perception, it is possible that this factor could have some influence on the pilot’s decision to proceed for the landing in Congonhas, in spite of his concern with the runway operating conditions. This factor was considered undetermined due to the impossibility to confirm its contribution in factual terms.

g. Regulation - A contributor
The regulatory organization, although having already considered the availability of the reversers as a requirement for the operation in Congonhas, at least since April 2006, such a requirement was only formalized as a norm in May 2008. The opportune regulation of this requisite would have prevented the aircraft from operating in Congonhas with a wet runway condition.

h. Training - Undetermined
In relation to the training, the investigation identified in the crews a perception that the company seemed to have reduced the contact hours applied to it, although in formal terms those contact hours had remained unaltered. In relation to crew professional formation, the investigation identified a tendency on the part of the company to reduce the number of hours assigned to training, which remained unaltered in formal terms. Moreover, the FDR recordings showed that, during the period in which the aircraft operated with the pinned reverser, 5 different types of landing procedures were performed by the various crews who operated it. This factor was considered undetermined due to the impossibility to confirm, in factual terms, that the crews’ perception of a shortening in the training processes being applied was consistent with reality and/or whether such alleged shortening effectively influenced the performance of the crew, contributing to the accident.

2 Material factors
a. Design - A contributor
It was verified that, for an A320 airplane proceeding to land, it is possible to place one of the thrust levers at the “REV” position and the other at “CL”, and no alerting device will advise the pilots in an efficient way. This situation may put the aircraft in a critical condition and, depending on the time it takes the crew to identify this configuration, and on the runway parameters, a catastrophic situation may occur. In the specific case of this accident, even with the aircraft on the ground (Weight on Wheels - WOW), with the number 1 engine thrust lever at the “REV” position, with the ground spoilers armed, with the autobrake selected, and with application of maximum braking pressure on the pedals, the power control system gave priority to the information that one of the levers was at “CL”, and this lever did not have any safety devices regarding a possible inadvertent setting.
Final Report:

Crash of an ATR42-300 in São Paulo

Date & Time: Jul 16, 2007 at 1242 LT
Type of aircraft:
Operator:
Registration:
PT-MFK
Survivors:
Yes
Schedule:
Araçatuba – Bauru – São Paulo
MSN:
225
YOM:
1991
Flight number:
PTN4763
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7420
Captain / Total hours on type:
4993.00
Copilot / Total flying hours:
947
Copilot / Total hours on type:
797
Circumstances:
The aircraft departed Araçatuba on a flight to São Paulo with an intermediate stop in Bauru, carrying 21 passengers and a crew of four. After touchdown on wet runway 17R at Congonhas Airport, the crew started the braking procedure when the aircraft deviated to the left and veered off runway. While contacting soft ground, the aircraft collided with a concrete block housing the electrical device supplying the runway light system. On impact, the nose gear was torn off and the aircraft came to rest. All 25 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Loss of control upon landing after the aircraft suffered aquaplaning. The following contributing factors were identified:
- A light rain caused the presence of water on the runway, enabling the occurrence of hydroplaning.
- The accumulation of water on the surface of the runway, as a result of inadequate drainage, lack of "grooving", enabled the hydroplaning.
- The pilot applied full pressure on the right pedal, generating a force to the left that contributed to the departure off the runway.
- During hydroplaning, the pilot should not apply pedal to the opposite side to which the aircraft slides; this fact was not covered during the instruction of the pilot.
- In the face of hydroplaning, the pilot applied the right pedal, aggravating the departure of the aircraft to the left.
Final Report: