Accident
Last updated: 27 August 2014
Status:Definitief
Datum:vrijdag 31 maart 2006
Tijd:17:39
Type:Silhouette image of generic L410 model; specific model in this crash may look slightly different
Let L-410UVP-E20
Luchtvaartmaatschappij:TEAM Transportes Aťreos
Registratie: PT-FSE
Constructienummer: 912532
Bouwjaar: 1991
Aantal vlieguren:2739
Aantal vluchten:3960
Motoren: 2 Walter M-601E
Bemanning:slachtoffers: 2 / inzittenden: 2
Passagiers:slachtoffers: 17 / inzittenden: 17
Totaal:slachtoffers: 19 / inzittenden: 19
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:6 km (3.8 mijl) SE of Rio Bonito, RJ (   BraziliŽ) show on map
Fase: Kruisvlucht (ENR)
Soort vlucht:Binnenlandse lijnvlucht
Vliegveld van vertrek:Macať Airport, RJ (MEA/SBME), BraziliŽ
Vliegveld van aankomst:Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ), BraziliŽ
Vluchtnummer:6865
Beschrijving:
TEAM Flight 6865 departed Macať (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

Bronnen:
» Avi„o da Team com 19 pessoas a bordo ť 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: Relatůrio Final ť referente ao acidente ocorrido com a aeronave LET-410, PT-FSE, operado pela TEAM (RF A-005/CENIPA/2007)
cover

Foto's

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
 

Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Macať Airport, RJ en Rio de Janeiro-Santos Dumont Airport, RJ bedraagt 156 km (98 miles).

languages: English FranÁais Nederlands Deutsch Espanol

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Let L-410

  • 83e ongeval
  • 1138+ built
  • 3e zwaarste ongeval (toen het plaatsvond)
  • 4e zwaarste ongeval (op dit moment)
safety profile

 BraziliŽ
  • 48e zwaarste ongeval (toen het plaatsvond)
  • 51e zwaarste ongeval (op dit moment)
»safety profile