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Crash of a Fokker F27 Friendship 600 in Tarauacá

Date & Time: Oct 20, 2003 at 1132 LT
Type of aircraft:
Operator:
Registration:
PT-TVA
Survivors:
Yes
Schedule:
Cruzeiro do Sul – Tarauacá – Rio Branco
MSN:
10334
YOM:
1967
Flight number:
TVJ6167
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
3797.00
Copilot / Total hours on type:
2682
Aircraft flight hours:
55725
Aircraft flight cycles:
60270
Circumstances:
After landing at Tarauacá Airport, the crew started the braking procedure when control was lost. The aircraft veered off runway, collided with several obstacles and came to rest in a ditch. All 23 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control after landing after the crew selected the power levers on 'ground fine pitch', combined with the failure of the antiskid system due to poor maintenance. The operator was facing enormous financial difficulties which affected the motivation of the maintenance, flight and cabin crew, which was considered as a contributing factor.
Final Report:

Crash of a Boeing 737-2M9 in Rio Branco

Date & Time: Jan 26, 2003 at 1415 LT
Type of aircraft:
Operator:
Registration:
PP-SPJ
Survivors:
Yes
Schedule:
Belém – Manaus – Rio Branco
MSN:
21236
YOM:
1976
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
89
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7120
Captain / Total hours on type:
5271.00
Copilot / Total flying hours:
1348
Copilot / Total hours on type:
310
Aircraft flight hours:
54989
Circumstances:
Following an uneventful flight from Manaus, the crew started the descent to Rio Branco-Presidente Médici Airport runway 06 in marginal weather conditions with limited visibility due to fog. After passing the MDA at 1,150 feet, the crew continued the approach with an excessive rate of descent of 1,222 feet per minute. At a height of 57 feet, the aircraft struck trees located 360 metres short of runway 06 threshold. The engines lost power, the aircraft lost speed and height then struck the ground about 100 metres short of runway. Upon impact, the undercarriage were torn off and the aircraft slid on a distance of 600 metres before coming to rest. All 95 occupants escaped uninjured while the aircraft was destroyed.
Probable cause:
Poor approach configuration on part of the flying crew who continued the approach after passing the MDA at 1,150 feet while the aircraft was not stabilized and the crew did not establish a visual contact with the obstacles on short final. The following contributing factors were identified:
- Following the first impact with trees, branches and pieces of wood entered the engines, causing a loss of power followed by a loss of speed and altitude,
- Complacency on the part of the crew,
- Pressure and stress,
- Visual perception issues,
- Violation of the standard operating procedures,
- Loss of situational awareness,
- Lack of crew resources management,
- Poor approach and landing planning,
- Poor weather conditions,
- Relative low experience of the copilot.
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:

Crash of a Britten-Norman BN-2A-27 in Bujari

Date & Time: Sep 22, 2001 at 1207 LT
Type of aircraft:
Operator:
Registration:
PT-KTQ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rio Branco - Rio Branco
MSN:
493
YOM:
1976
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
300.00
Circumstances:
The twin engine aircraft departed Rio Branco with four passengers and one pilot on board. The goal of the flight was to carry four Japanese journalists who wanted to perform aerial views from various tribes located in the region of Santa Rosa do Purus. About 30 minutes into the flight, an oil leak occurred on the left engine that lost power. The pilot reduced his altitude and attempted an emergency landing when the aircraft crashed near Bujari, about 39 km from Rio Branco. The wreckage was found near motorway BR364 and all five occupants were slightly injured.
Probable cause:
The following findings were identified:
- It is likely that the pilot did not use the controls properly to maintain an adequate control of the airplane in a single-engine configuration while the airplane was operated within weight and balance limits,
- The left propeller retainer had been replaced by similar but not original equipment, using glue to ensure its tightness, which was non compliant with the engine manufacturer's procedures,
- The aircraft maintenance documents were not kept up to date by the operator,
- Poor flight preparation on the part of the pilot who did not notice that the maintenance documents were not up to date,
- The operator was not compliant with the current Brazilian Civil Aviation Authority legislation.
Final Report:

Crash of an Embraer EMB-110EJ Bandeirante in Feijó: 2 killed

Date & Time: Sep 23, 1994 at 0635 LT
Operator:
Registration:
PT-GJY
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Feijó - Tarauacá - Rio Branco
MSN:
110-087
YOM:
1976
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4095
Captain / Total hours on type:
1119.00
Copilot / Total flying hours:
647
Copilot / Total hours on type:
187
Aircraft flight hours:
21502
Circumstances:
The aircraft was completing a cargo flight from Feijó to Rio Branco with an intermediate stop in Tarauacá, carrying two pilots and a load of 635 kilos of various goods. As the flight to Tarauacá was 10 minutes only, the crew decided to leave the undercarriage down. Shortly after takeoff from Feijó Airport, the crew encountered technical problems with the right engine. The aircraft lost speed and height so the captain decided to raise the landing gear but this was too late. The aircraft struck a tree, causing 3,2 metres of the right wing to be torn off. Out of control, the aircraft crashed in a wooded area, bursting into flames. Both pilots were killed.
Probable cause:
It was determined that the evening prior to the accident, the aircraft suffered an incident upon landing at Feijó Airport. Upon landing the copilot inadvertently mishandled the engines. Reverse pitch was not applied. Directional control was lost and the left main landing gear ran off the side of the runway. The airplane came to rest 40 metres past the runway end. It was towed to the ramp and the captain conducted an inspection of the airplane. As nothing wrong was noticed, the crew decided to continue the flight after the company base was notified of the occurrence. At the time of the accident, the crew was anxious about the event that occurred the preceding evening and the captain's attention was distracted. Thus, there was a higher level of stress in the cockpit at the time of the accident and the copilot did not want to be the PIC for the second leg due to anxiousness. As the right engine was totally destroyed by a post crash fire, it was not possible to determine the exact cause of its malfunction. Poor weather conditions, poor flight planning and insufficient control inputs on the rudder were considered as contributing factors.
Final Report:

Crash of a Boeing 737-2A1C in Cruzeiro do Sul: 3 killed

Date & Time: Jun 22, 1992 at 0605 LT
Type of aircraft:
Operator:
Registration:
PP-SND
Flight Type:
Survivors:
No
Schedule:
Rio Branco - Cruzeiro do Sul
MSN:
21188
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
4581
Captain / Total hours on type:
3081.00
Copilot / Total flying hours:
2437
Copilot / Total hours on type:
337
Aircraft flight hours:
31980
Circumstances:
While descending to Cruzeiro do Sul Airport by night and good weather conditions, the crew encountered problems with the intermittent activation of a warning light in the instrument panel, warning them of a fire in the cargo compartment. On final approach, the aircraft struck trees and crashed in a dense wooded area located in hilly terrain. The wreckage was found 15 km from runway 10 threshold and all three occupants were killed.
Probable cause:
The following findings were reported:
a. Human Factor
(1) Physiological Aspect
- There was no evidence of this aspect contributing to the occurrence of the accident.
(2) Psychological Aspect - Contributed
- The psychological aspect contributed through the generation of a high level of anxiety to perform the landing and in the diversion of the focus of attention during the approach manoeuvres to land.
- The psychological aspect was influenced by the activation of the smoke alarm which generated an increase in the workload on board.
b. Material Factor
- There were no indications that this factor contributed to the accident.
c. Operational Factor
(1) Deficient Instruction
- Although the instruction was carried out in accordance with what the standards recommend, the failures that contributed to the accident are characteristic of lack of experience in facing abnormalities simultaneously with the maintenance of flight control. Such failures could be avoided with more adequate simulator instructions and training involving the cockpit management aspects.
(2) Poor Maintenance - Undetermined .
- It was not possible to determine the cause of the activation of the 'Aft Cargo Smoke' alarm and whether the maintenance services contributed to this occurrence.
(3) Deficient Cockpit Coordination
- Inadequate performance of the duties assigned to each crew member. The procedures foreseen for the execution of descent by instrument have been modified and some have been deleted depending on the appearance of a complicator element (smoke alarm).
(4) Influence of the environment
- The dark night contributed to the creation of the 'black hole' phenomenon, or 'background figure', making it difficult to perceive external references for a possible identification of the vertical distance of the aircraft from the ground.
(5) Deficient Oversight
- The supervision, at cockpit level, contributed to the accident by the inadequate management of the resources available for the flight in the cockpit.
- Company level supervision contributed to the accident by not identifying the need for cockpit management training and providing it to the crew involved.
- Supervision, at company level, was also inadequate when climbing to the same mission, two pilots unfamiliar with the airplane to be used and in night operation.
(6) Other Operational Aspects
- The failure to comply with several 'Callouts', the non-use of the radio altimeter and the inadequate use of the 'altitude alert', as an aid to the accomplishment of the descent procedure, contributed to the occurrence of the accident.
Final Report:

Crash of a Learjet 25B in Rio Branco: 10 killed

Date & Time: Sep 4, 1982
Type of aircraft:
Operator:
Registration:
PT-JBQ
Flight Type:
Survivors:
No
Schedule:
Porto Velho – Rio Branco
MSN:
25-119
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
The approach to Rio Branco-Presidente Médici Airport was initiated in poor weather conditions. On final approach in rain falls, the crew was unable to locate the unlighted runway and decided to initiate a go-around. A second approach was abandoned few minutes later for the same reasons. During a third attempt to land, the airplane stalled and crashed 5 km from the airport. It was destroyed on impact and all 10 occupants were killed.
Probable cause:
Failure of both engines on final approach due to fuel exhaustion following three unsuccessful approaches. The following contributing factors were reported:
- Poor weather conditions,
- Poor visibility,
- Poor flight planning,
- Lack of Company assistance,
- Operational deficiencies,
- Infrastructures deficiencies.

Crash of a De Havilland C-115 Buffalo in Rio Branco

Date & Time: Mar 16, 1978
Type of aircraft:
Operator:
Registration:
2358
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Rio Branco – Cruzeiro do Sul
MSN:
28
YOM:
1968
Location:
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The airplane was completing a flight from Rio Branco to Cruzeiro do Sul, carrying five tons of rice and beans. In unclear circumstances, it struck a truck while taking off and the decision to return was taken. One of the main landing gear could not be lowered so the crew burned the fuel and jettisoned 30 sacks of cargo. The aircraft belly landed and came to rest. There were no injuries but the aircraft was damaged beyond repair.

Crash of a Lockheed L-049 Constellation near Cruzeiro do Sul: 9 killed

Date & Time: May 29, 1972
Registration:
PP-PDG
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cruzeiro do Sul - Rio Branco
MSN:
2037
YOM:
1946
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Because of a lack of fuel at Cruzeiro do Sul Airport, the airplane was grounded for four days. Eventually, two fuel trucks were dispatched to the airport and the aircraft could be refueled directly from the trucks. Few minutes after takeoff, while cruising at an altitude of 8,000 feet, the engine n°3 failed, followed 10 minutes later by a second engine. Some of the cargo was jettisoned but the aircraft was still losing altitude. The captain decided to attempt an emergency landing on the Cruzeiro do Sul - Tarauacá highway when the airplane struck trees and crashed in a wooded area. Nine occupants were killed, including all three crew members, and nine other occupants were injured. The aircraft was destroyed. It was later confirmed that another aircraft that had been refueled just after PP-PDG had to reject its takeoff because of an engine failure.
Probable cause:
Refueling directly from the trucks without allowing sufficient time for the fuel to settle.

Crash of a Douglas DC-3-414A in Sena Madureira: 32 killed

Date & Time: Sep 28, 1971 at 1200 LT
Type of aircraft:
Operator:
Registration:
PP-CBV
Flight Phase:
Survivors:
No
Schedule:
Sena Madureira - Rio Branco
MSN:
4977
YOM:
1943
Flight number:
SC332
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
32
Circumstances:
Shortly after takeoff from Sena Madureira Airport, while climbing, the pilot declared an emergency and elected to return following an engine failure. He completed a circuit at low altitude and while completing a turn to the right, the airplane struck trees and crashed in flames in a dense wooded area located few km from the airport. The aircraft was totally destroyed and all 32 occupants were killed.
Probable cause:
Engine failure during initial climb.