Accident
Last updated: 28 August 2014
Statuts:Enquête Officielle
Date:vendredi 31 mars 2006
Heure:17:39
Type/Sous-type:Silhouette image of generic L410 model; specific model in this crash may look slightly different
Let L-410UVP-E20
Compagnie:TEAM Transportes Aéreos
Immatriculation: PT-FSE
Numéro de série: 912532
Année de Fabrication: 1991
Heures de vol:2739
Cycles:3960
Moteurs: 2 Walter M-601E
Equipage:victimes: 2 / à bord: 2
Passagers:victimes: 17 / à bord: 17
Total:victimes: 19 / à bord: 19
Dégats de l'appareil: Détruit
Conséquences: Written off (damaged beyond repair)
Lieu de l'accident:6 km (3.8 milles) SE of Rio Bonito, RJ (   Brésil) show on map
Élévation des lieux de l'accident: 585 m (1919 feet) amsl
Phase de vol: En vol (ENR)
Nature:Transport de Passagers Nat.
Aéroport de départ:Macaé Airport, RJ (MEA/SBME), Brésil
Aéroport de destination:Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ), Brésil
Numéro de vol:6865
Détails:
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.

Operational Aspect
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

Sources:
» Avião da Team com 19 pessoas a bordo é encontrado sem sobreviventes no Rio (Folha Online, 1-4-2006)

Official accident investigation report
investigating agency: Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) - Brazil
report status: Final
report number: RF A-005/CENIPA/2007
report released:19-MAR-2007
duration of investigation:353 days (11.8 months)
download report: Relatório Final é referente ao acidente ocorrido com a aeronave LET-410, PT-FSE, operado pela TEAM (RF A-005/CENIPA/2007)
cover

Photos

photo of Let 410UVP-E20 OY-TCM
OY-TCM moved to Brazil in March 2001 as PT-FSE, operating for Aerostar until TEAM bought the plane in 2006.
Add your photo of this accident or aircraft
 

Plan
Ce plan montre l'aéroport de départ ainsi que la supposé destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Macaé Airport, RJ et Rio de Janeiro-Santos Dumont Airport, RJ est de 156 km (98 miles).

languages: English Français Nederlands Deutsch Espanol

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