Narrative:TEAM Flight 6865 departed Macaé (MEA) at 17:19 on an IFR flight plan to Rio de Janeiro (SDU). The airplane was expected to arrive at 18:02. After takeoff the crew requested cancellation of their IFR flight plan ant to continue under visual flight rules at FL045. This was approved. Upon request, the flight was cleared to descend to 2000 feet to avoid an area of poor weather. About 17:39 a left turn was initiated towards the coast line for the same reason. The airplane struck trees near the top of Pico da Pedra Bonita at an elevation of 1920 feet.
CONTRIBUTING FACTORS (translated from Portuguese)
1. Human factors
Psychological - Contributed
It was found that the decision of the crew to cancel the IFR plan to continue VFR at low altitude and when visibility is not favorable, has been inadequate, with compliance of the pilots with such a decision.
It is possible that the knowledge of the region obtained by the instructor captain caused over-confidence, influencing the decision.
The organizational culture of the company proved to be complacent by not inhibiting the adoption of procedures incompatible with flight safety, such as the low altitude flights made by the instructor captain.
a. Judgement - Contributed
There was inadequate assessment of the situation by the crew, causing them to fly at a lower altitude than the safe limits under visual conditions unsuitable for visual flight, resulting in the collision of the aircraft with high ground.
b. Coordination Cabin - Contributed
The use of human resources for the operation of the aircraft was unsuitable because of failure to comply with operational standards, leading the crew to perform a passenger flight to the lower altitude limits of safety, under inadequate visual conditions.
c. Planning - Contributed
The preparation for the flight proved inadequate because the crew did not have a meteorological analysis of the appropriate level of flight performed, considering that the conditions for the region were overshadowing the Serra do Mar and surrounding areas of low clouds and / or mist, especially on the slopes of the mountain.
d. Adverse weather conditions - Contributors
The weather conditions prevailing in the region made visual flight impossible, resulting in the concealment of the elevation at which the aircraft crashed.
e. Flight indiscipline - Contributed
The pilots intentionally not complying with rules of air traffic and civil aviation rules, without grounds, performing flight at low altitude, under conditions of visibility below the limits established for VFR flight, colliding with high ground.
f Supervision - Contributed
The company has not taken appropriate supervisory measures, enabling the existence of a culture of undeveloped flight safety, which prevented advance identification of actions taken by the crew and injured misconception exists in the CRM business, which represented a potential risk to their operations, as well as by the failure of some educational measures provided for in its PPAA (Plan for the Prevention of Aeronautical Accidents).
2 Material Factor
Not contributed. Not contributed
Controlled Flight Into Terrain (CFIT) - Mountain
» Avião da Team com 19 pessoas a bordo é encontrado sem sobreviventes no Rio (Folha Online, 1-4-2006)
Official accident investigation report
OY-TCM moved to Brazil in March 2001 as PT-FSE, operating for Aerostar until TEAM bought the plane in 2006.
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 Macaé Airport, RJ to Rio de Janeiro-Santos Dumont Airport, RJ as the crow flies is 156 km (98 miles).