São Paulo-Guarulhos

Operator:

Registration:

PT-MST

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Belém – Brasilía – São Paulo

MSN:

18711

YOM:

1964

Flight number:

SKC9101

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4200

Captain / Total hours on type:

2543.00

Copilot / Total flying hours:

3858

Copilot / Total hours on type:

361

Aircraft flight hours:

70422

Aircraft flight cycles:

28047

Circumstances:

The aircraft was completing a cargo flight from Belém to São Paulo with an intermediate stop in Brasilía, carrying three crew members and a load of various goods such as mail and fish. While descending to São Paulo-Guarulhos Airport in good weather conditions at an altitude of 10,000 feet, the crew encountered technical problems with the trim system. Several manual controls and tests were conducted and the system worked before failing again between 6,000 and 4,700 feet. The captain decided to continue the approach but the aircraft became unstable and nosed down on short final. It landed hard on runway 09R, causing the undercarriage to be torn off. The aircraft slid for about 1,000 metres then veered off runway to the left and came to rest in a grassy area. All three crew members escaped uninjured while the aircraft was damaged beyond repair.

Probable cause:

The exact cause of the technical problems on the trim system could not be determined with certainty. The following contributing factors were identified:
- The decisions of the crew and more particularly of the captain during the last phase of flight were incorrect,
- The crew training program for emergency situation was incomplete,
- Improper use of flaps and slats on final approach made the situation worse,
- The captain did not follow the procedure determined for such an emergency situation and decided to continue the approach maneuver, increasing the risk margin and placing the airplane in critical operating conditions,
- Due to deviations from the published standard operational procedures, such as failure to complete the approach briefing and not following the approach checklist, the coordination among the flight crew was poor, leading to further deviations and putting the crew in a critical situation.

Final Report:

Crash of a Cessna 208A Caravan I in Bairro Guriri

Date & Time: Oct 18, 1997 at 0545 LT

Type of aircraft:

Cessna 208A Caravan

Operator:

Registration:

PT-OGC

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Vitória – São Paulo

MSN:

208A-0064

YOM:

1985

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

11000

Captain / Total hours on type:

600.00

Copilot / Total flying hours:

800

Copilot / Total hours on type:

400

Aircraft flight hours:

9633

Circumstances:

The crew was completing a cargo flight from Vitória to São Paulo-Guarulhos Airport. About forty minutes after departure from Vitória, while cruising over the ocean at an altitude of 8,000 feet, the engine failed. The crew heard a metallic noise when oil spread from the engine on the windshield. The crew reduced his altitude and attempted to reach the coast but due to clouds and limited visibility, he eventually decided to attempt an emergency landing on a beach. The aircraft crash landed and came to rest. The copilot escaped uninjured while the captain was slightly injured.

Probable cause:

It was determined that the engine failure was probably caused by the failure of a blade on the high-pressure compressor, possibly as a result of a manufacturing defect. The following contributing factors were identified:
- The crew failed to feather the propeller after the engine failure,
- The flaps were lowered at an angle that caused a speed reduction,
- Lack of crew coordination,
- The crew failed to follow strictly the checklist and missed certain points,
- The fact that the crew was flying under IFR mode at the time the engine failed aggravated the situation, making it difficult to carry out the planned procedures and ruling out an early choice of an emergency landing site,
- The poor visibility due to the night impeded a proper choice and planning of the emergency landing procedure.

Final Report:

Crash of a Learjet 25D in São Paulo: 9 killed

Date & Time: Mar 2, 1996 at 2316 LT

Type of aircraft:

Learjet 25

Operator:

Madrid Taxi Aéreo

Registration:

PT-LSD

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Brasília – São Paulo

MSN:

25-243

YOM:

1978

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2500

Captain / Total hours on type:

220.00

Copilot / Total flying hours:

330

Copilot / Total hours on type:

Aircraft flight hours:

6123

Circumstances:

The twin engine aircraft was completing a charter flight from Brasília to São Paulo, carrying seven members of the pop music group 'Mamonas Assassinas' and two pilots. On approach in limited visibility due to the night, absence of ground lights and clouds, the crew initiated a go-around as his position was erroneous (too high and the glide and excessive speed). The captain initiated a turn to the left when shortly later, at an altitude of 3,280 feet, the aircraft struck trees and crashed in a dense wooded area located about 11 km from the airport. The aircraft was destroyed by impact forces and all nine occupants were killed.

Probable cause:

The following findings were reported:
- The crew was tired due to a long duty period of 16 hours and 30 minutes without rest time,
- The captain showed excess of self-confidence,
- Physical fatigue worsened the level of situational stress of the crew,
- Lack of crew training programme,
- Poor crew coordination,
- Poor approach and landing planning,
- Lack of visibility, lack of ground lights (environment) and low clouds,
- The crew failed to follow the missed approach procedures,
- The copilot was inexperienced,
- Instead of a right turn to 092° and continue to 6,000 feet, the captain initiated a left turn, causing the aircraft to struck obstacles.

Final Report:

Crash of a Boeing 737-2A1 in São Paulo

Date & Time: Feb 2, 1995 at 0008 LT

Type of aircraft:

Boeing 737-200

Operator:

Registration:

PP-SMV

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

São Paulo – Buenos Aires

MSN:

20968

YOM:

1974

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

121

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

8000

Captain / Total hours on type:

6500.00

Copilot / Total flying hours:

4500

Copilot / Total hours on type:

2500

Circumstances:

Following a night takeoff from São Paulo-Guarulhos Airport, en route to Buenos Aires, the captain informed ATC about technical problems and was cleared to return for an emergency landing. The aircraft landed at a speed of 185 knots with flaps down to 15° on wet runway 09L. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest 200 metres further. All 128 occupants were evacuated safely, among them two passengers were slightly injured. The aircraft was written off.

Probable cause:

It was determined that the n°3 leading edge flap actuator attachment fitting on the wing front spar had fractured due to corrosion. The actuator came away and caused the failure of some hydraulic lines and damage to the thrust control cables. Some 1981 Boeing Service Bulletins had not been complied with. One of these included the replacement of the aluminium leading edge flap actuator attachment fitting with a steel one; this had not been done. The following contributing factors were reported:
- Excessive workload on approach and landing due to the emergency situation,
- Poor approach planning,
- Lack of visibility due to the night,
- Poor crew coordination,
- Poor crew resources management,
- The crew forgot to lower the flaps electrically on approach, causing the speed to be 32 knots in excess,
- Poor aircraft maintenance and supervision,
- Failures in the supervision of the Company's operating sector.

Final Report:

Crash of a Boeing 707-324C in São Paulo

Date & Time: Oct 9, 1994 at 1742 LT

Type of aircraft:

Operator:

Registration:

HK-3355X

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Campinas - Santa Cruz

MSN:

18886

YOM:

1965

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

After takeoff from Campinas-Viracopos Airport, while climbing, the crew informed ATC about technical problems and was cleared to divert to São Paulo-Guarulhos Airport for an emergency landing. On final, both main landing gears were lowered but apparently not locked while the nose gear remained stuck in its main wheel. Upon touchdown on runway 09L, the aircraft sank on its belly and slid for few dozen metres before coming to rest. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Probable cause:

It was determined that the hydraulic pump n°2 on the engine n°3 failed after takeoff, causing an oil leak and a loss of hydraulic pressure. The undercarriage could be lowered but not locked down while the crew attempted to lower the nose gear manually but doing so, caused the locking pin to obstruct and damage the landing gear extension system. It was also reported that several seals located on hydraulic lines were broken and have not been replaced during the last C check.

Crash of a Boeing 707-349C in São Paulo: 25 killed

Date & Time: Mar 21, 1989 at 1155 LT

Type of aircraft:

Operator:

Registration:

PT-TCS

Flight Phase:

Flight Type:

Survivors:

Site:

City

Schedule:

Manaus – São Paulo

MSN:

19354

YOM:

1966

Flight number:

TR801

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

10731

Captain / Total hours on type:

1458.00

Copilot / Total flying hours:

2265

Copilot / Total hours on type:

Aircraft flight hours:

61053

Circumstances:

The crew (one captain under training, one instructor and one flight engineer) was completing a cargo flight from Manaus to São Paulo and the aircraft was carrying a load of 26 tons of electronic equipments. Initially cleared for an approach to runway 09L, the crew was instructed to change to runway 09R as runway 09L was blocked by an aircraft. The crew was aware of a notam saying that runway 09R would be closed to all traffic starting 1200LT due to maintenance. In such conditions, the instructor rushed the approach procedure, interrupted the instruction to the captain under supervision and commanded flaps and speed brake at the same time, causing the aircraft to descend. The left wing struck the roof of a house then crashed in a residential area located about 2,7 km short of runway, bursting into flames. All three crew members and 22 people on the ground were killed. 47 other people on the ground were seriously injured.

Probable cause:

The accident was the consequence of the combination of the following factors (findings):
- The imminent interruption of operations in the aerodrome that would be used for landing the aircraft (closure of runway 09R due to works) stimulated the instructor to make a hurried descent, characterizing a potential state of anxiety,
- Probable crew fatigue,
- The instruction given to the pilot was discontinued and the local flight did not comply with the minima provided in RAC 3211,
- The failures found in the instruction were due to poor supervision of the Company's operations sector,
- Poor crew coordination,
- During the descent procedure when working checklist, the instructor broke the sequence of standardized procedures, thus stopping the instruction and consequently, the student's core handling of the flight,
- The instructor, without the student being informed beforehand, commanded the flaps together with the speed brakes. This action configured an abnormal attitude that contributed, without the pilots identifying, to the loss of control of the aircraft,
- The flight engineer also failed to meet the checklist items,
- The instructor did not follow the standardization of the instruction, when he executed a decision in a hurry,
- The crew did not respond to the sinking and pull up warnings,
- Error in the application of flight controls,
- The crew did not operate in accordance with the operational standard issued by the manufacturer and endorsed by the company,
- The air traffic controller contributed to the increase of the crew anxiety level by using non standard phraseology.

Final Report:

Crash of a Boeing 737-2A1 in São Paulo: 1 killed

Date & Time: Jan 28, 1986 at 0732 LT

Type of aircraft:

Boeing 737-200

Operator:

Registration:

PP-SME

Flight Phase:

Takeoff (climb)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

São Paulo – Belo Horizonte

MSN:

20096

YOM:

1969

Flight number:

VP210

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The crew left the apron and taxied to the runway threshold for takeoff on a regular schedule service VP210 to Belo Horizonte. Due to foggy conditions, the visibility was nil and the crew mistakenly lined up on the 'threshold' of the taxiway instead of the runway. Unaware of the wrong position of the aircraft, the crew was cleared for takeoff by ATC and started the takeoff procedure. After few seconds, the captain realize the situation and initiated an emergency braking maneuver. Unable to stop within the remaining distance, the aircraft overran, struck an embankment and came to rest, broken in two. A passenger was killed, 20 other occupants were injured and the aircraft was destroyed.

Probable cause:

Failure of the crew to recognize that he was lined up on a taxiway and not the active runway. Poor visibility due to foggy conditions was a contributing factor.

Crash of a Boeing 707-387C in Buenos Aires

Date & Time: Jan 27, 1986 at 0759 LT

Type of aircraft:

Operator:

Registration:

LV-JGR

Flight Phase:

Flight Type:

Survivors:

Site: