Statuts: | Accident investigation report completed and information captured |
Date: | mercredi 21 octobre 1998 |
Heure: | 08:51 |
Type/Sous-type: | Embraer EMB-120RT Brasilia |
Compagnie: | Capital Táxi Aéreo |
Immatriculation: | PT-WKH |
Numéro de série: | 120076 |
Année de Fabrication: | 1988 |
Moteurs: | 2 Pratt & Whitney Canada PW118 |
Equipage: | victimes: 2 / à bord: 2 |
Passagers: | victimes: 1 / à bord: 1 |
Total: | victimes: 3 / à bord: 3 |
Victimes au sol: | victimes: 1 |
Dégats de l'appareil: | Perte Totale |
Conséquences: | Written off (damaged beyond repair) |
Lieu de l'accident: | ca 2 km from Fortaleza-Pinto Martins Airport, CE (FOR) ( Brésil)
|
Phase de vol: | En approche (APR) |
Nature: | Cargo |
Aéroport de départ: | Teresina-Senador Petrônio Portela Airport, PI (THE/SBTE), Brésil |
Aéroport de destination: | Fortaleza-Pinto Martins Airport, CE (FOR/SBFZ), Brésil |
Détails:The Emb-120 carried 2.5 tons of medicines from Teresina to Fortaleza. During the descent for Fortaleza, the crew requested a visual approach with right base leg runway 13. The approach was flown at high speed. Flaps and land gear were selected at a higher speed than authorized. The unstabilized approach was not abandoned and the copilot, who was pilot non flying, did not intervene. On finals the thrust levers were positioned below the flight idle position. The airplane entered an uncontrolled right hand turn, ripped through electrical cables and tore across several rooftops before smashing into a brick house, killing a woman inside. Seven other people were injured in either the resulting fires or by flying debris.
Probable Cause:
CONCLUSION:
Human Factor - Psychological Aspect - Contributed.
In the individual aspect, there were signs of concern of the crew member with prolonged waiting caused by the local traffic in Fortaleza and by another traffic that was approaching the aerodrome and, because of this, accelerated the procedure of the final approach, descending at high speed and triggering the other operational failures that led to the accident; in the same way, there were signs of excessive self-confidence by the pilot.
Operational Factor
(1). Deficient Maintenance - Indetermined.
The operator's delay in submitting the requested documentation for the aircraft reduced the credibility of the submitted material. The possibility that the secondary stop was deactivated, despite statements to the contrary by a mechanic, would have been caused by inadequate participation of maintenance personnel in the services performed and by non-compliance with the planned AD.
(2). Deficient Supervision - Indeterminate.
There are reports from several pilots about this commander's habits of performing unforeseen procedures, including some that avoided flying with him. It was not researched if the other crew members took this fact to the company's management. The company's response was not researched if it was aware of these operational deviations.
(3). Deficient Cabin Coordination - Contributed.
The pilot misused the resources available in the operation of the aircraft, due to ineffective management of the tasks related to the PF and PNF and the noncompliance with operational rules.
The PNF did not advise the PF during the approach. The PNF accepted the non-stabilized approach and did not react to reverse the situation.
(4). Deficient Judgement - Contributed.
The crew made the approach above the glide slope and at high speed; thought inappropriately that it could proceed in those conditions and that there would be ways to reduce the speed and make the landing.
(5). Flight Indiscipline - Contributed.
The crew disobeyed the aircraft's operating rules by performing a destabilized approach outside the envelope recommended by the manufacturer and by placing the power levers below the flight idle position.
Accident investigation:
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Investigating agency: | CENIPA Brazil |
Status: | Investigation completed |
Accident number: | final report | Download report: | Final report
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Sources:
» CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos
Photos
accident date:
21-10-1998type: Embraer 120RT Brasilia
registration: D-CEML
Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Teresina-Senador Petrônio Portela Airport, PI et Fortaleza-Pinto Martins Airport, CE est de 494 km (309 miles).
Accident location: Approximate; accuracy within a few kilometers.
Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.