Narrative:An ATR-42 cargo plane was destroyed when it crashed near Paranapanema, SP, Brazil. Both crew members were killed.
TOTAL Linhas Aéreas Flight 5561, departed São Paulo-Guarulhos (GRU) at 04:52 on a domestic flight to Londrina Airport, PR (LDB). The ATR climbed to FL180 and the flight progressed uneventful until 05:37. At that time the autopilot disconnected. The crew faced an elevator pitch trim runaway. There was no emergency checklist available for this situation. Also, the pilots rarely received training for an event like this. The captain instructed the copilot to pull a specific circuit breaker. The copilot initially did not understand this instructions but later complied. Two seconds later the Vmo (maximum operating speed) alarm sounded and engine power was reduced to 10%.
The crew attempted to re-establish level flight but failed. The airplane descended out of control and struck the ground at a speed of 366 knots.
The ATR-42 departed São Paulo at 04:40 in the morning for a mail flight to Londrina and climbed to its cruising altitude of FL180. Twenty minutes later the
airplane crashed in a field near Paranapanema.
1. Human Factors
Psychological aspect - Contributing factor
The pilots' perception about the situation was affected by lack of specific training and procedures, which, coupled with the limited time available for action and lack of clarity in communications, influenced the time elapsed for taking corrective actions.
a) Coordination Cabin - Contributed
Communication between the crew was not clear at the time of emergency, making the co-pilot did not understand at first, the action to be performed, which increased the time spent to disarm the CB. Such facts, however, can not be separated from the situation experienced by pilots with inadequate training for emergency and in a short time to identify the problem and take the corrective actions.
b) Supervision - Undetermined
The company had not provided a regular CRM training to pilots. Furthermore, the captain did not receive simulator training for over one year. It was impossible to determine, however, if the regular training and updating of the CRM simulator training of the pilot would have prevented the accident.
c) Other Operational Issues - Undetermined
The removal of the pilot from his seat at the time of the emergency may have increased the time spent in identifying the crash and taking corrective actions, but it was not possible to establish whether the accident would be avoided if he would have been in the cockpit.
The co-pilot was slow to understand the situation and initiate corrective actions, although the alarm "whooler" has sounded, also increasing the elapsed time.
2. Material Factor
a) Project - Contributed
The operational testing under J IC 27-32-00 allowed the partial completion of the procedures due to lack of clarity, which allowed the release of the aircraft for flight with a defective relay.
Furthermore, although the elevator trim system has been certified, no procedure for emergency triggering of the compensator in the manuals provided by the manufacturer, no replacement intervals of the components of the elevator trim system in "Time Limits" systems normal and reserves were not independent and the system had a low tolerance for errors.
Loss of control
» Agência Estado
» ICAO Adrep
Follow-up / safety actions
On March 5, 2003, DGAC France issued Airworthiness Directive AD 2003-106(B), requiring an inspection and replacement (if needed) of the protective guard of the stand by pitch trim switch (18CG), installed on the centre pedestal.
In some cases, the AD states, a damaged protective guard, although engaged, may not prevent an inadvertent activation of the stand by pitch trim.
F-OGNE flew for Air Guadeloupe from 1986 until 1999. The aircraft then flew for Regional Airlines, Air Open Sky and Air Atlantique before being sold to Brazil.
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from São Paulo-Guarulhos International Airport, SP to Londrina Airport, PR as the crow flies is 474 km (296 miles).