Date:	Thursday 20 September 1990
Time:	19:40
Type:	Embraer EMB-110P1 Bandeirante
Owner/operator:	Governo do Estado de Pernambuco
Registration:	PT-FAW
MSN:	110368
Year of manufacture:	1982
Engine model:	Pratt & Whitney Canada PT6A-34
Fatalities:	Fatalities: 12 / Occupants: 12
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	off Fernando de Noronha Airport, FN (FEN) -   Brazil
Phase:	Initial climb
Nature:	Passenger - Scheduled
Departure airport:	Fernando de Noronha Airport, FN (FEN/SBFN)
Destination airport:	Recife-Guararapes International Airport, PE (REC/SBRF)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
Embraer 110 PT-FAW was being readied for a flight from the Fernando De Noronha Archipelago (FEN) to Recife (REC) on the mainland of Brazil. The aircraft had been on the ground for just 30 minutes when the engines were started again. The pre-departure checks were carried out by the first officer, while the captain arrived in a hurry. The aircraft was taxied out immediately and it is presumed that the crew did not carry out the pre-takeoff checklist. The airplane took off from runway 12, entered a steep climb and turned right. Shortly afterwards the airplane was seen to dive into the sea.
Investigation revealed that both pilots had very little experience on Bandeirante planes. Also, they had not flown such a plane in 141 (captain) and 133 days (first officer) days.

CONCLUSION:
Human Factor
(1) Physiological Aspect - Undetermined
There are indications of the contribution of this aspect with regard to the spatial disorientation of the crew.

(2) Psychological Aspect - Contributed
To the extent that the organization was not equipped with effective systems for monitoring and training of personnel.

Operational Factor
(1). Deficient Instruction - Contributed
For qualitative and quantitative deficiency of instruction, not attributing technical conditions necessary for the performance of the air activity.

(2). Deficient Maintenance - Contributed
The inadequacy of the corrective services performed on the aircraft.

(3). Deficient Application in the Command - Contributed
For the crew's ineptitude to allow the aircraft to engage in abnormal behavior.

(4). Deficient Cockpit Co-ordination - Contributed
The inadequate use of cockpit resources for the operation of the aircraft, and also failure to comply with operational standards.

(5). Influence of the Environment - Contributed
By the intrinsic characteristic of Fernando de Noronha aerodrome, as capable of causing spatial disorientation.

(6). Deficient - contributed
The inadequate assessment of certain operational aspects during the mission and the use of own piloting standards

(7). Little Flight Experience in the Aircraft - Contributed
For the reduced average of 44:00h of flight for the pilot and 73:00h for the co-pilot and, also, the crew leave for more than 120 days of air activity.

(8). Deficient Supervision - Contributed
The lack of supervision of the Air Transport Division in relation to planning and operational maintenance of its pilots, creating an undesirable climate of complacency in the organization.

(9). Other Operational Aspects - Contributed
By the intentional and unnecessary increase of the risk margin, when the pilots are not properly readapted, provided for in the RBHA-61, leaving the crew disqualified for the mission.

CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos

Date/time	Contributor	Updates
15-Mar-2024 19:58	ASN	Updated [Accident report]