ASN Wikibase Occurrence # 321366
| Date: | Monday 25 January 2010 |
| Time: | 14:30 |
| Type: |  Embraer EMB-110C Bandeirante |
| Owner/operator: | Piquiatuba Táxi Aéreo |
| Registration: | PT-TAF |
| MSN: | 110103 |
| Year of manufacture: | 1976 |
| Total airframe hrs: | 13012 hours |
| Engine model: | Pratt & Whitney Canada PT6A-27 |
| Fatalities: | Fatalities: 2 / Occupants: 10 |
| Aircraft damage: | Substantial, written off |
| Category: | Accident |
| Location: | 4 km E of Senador José Porfírio-Wilma Rebelo Airfield, PA -
 Brazil
|
| Phase: | Approach |
| Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
| Departure airport: | Belém/Val-de-Cans International Airport, PA (BEL/SBBE) |
| Senador José Porfírio-Wilma Rebelo Airfield, PA (SNWR) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
An Embraer EMB-110C Bandeirante passenger plane, registered PT-TAF and operated by Piquiatuba Táxi Aéreo, sustained substantial damage during a forced landing. The captain and one of the passengers were killed. The co-pilot and seven passengers survived.
The aircraft was en route from Belém/Val-de-Cães International Airport in Brazil to Senador José Porfírio at an altitude of 2500 feet when the no.1 engine showed an increase in TIT (Turbine Inlet Temperature). The captain throttled back the engine, but the aircraft was not able to maintain altitude. The crew attempted to locate their destination airport but were unable.
A forced landing was carried out 4 km from the airport.
Contributing Factors:
1 Human Factor
1.1 Medical Aspect
Not contributing.
1.2 Psychological Aspect
1.2.1 Individual Information
A) Attitude - contributed
There was disregard for the procedures, since the pilots did not use the checklist for the emergency situation.
1.2.2 Psychosocial Information
A) Culture of the working group - undetermined
It is possible that the informal rules, shared by some pilots, regarding the use of the checklist, have influenced the behavior of the pilot to decline its use.
1.2.3 Organizational Information
A) Organizational culture - contributed
The company evidenced to have an organizational culture based on the informality of the adopted procedures, from the planning to the maintenance of the aircraft, which compromised the safe accomplishment of the operation.
B) Organizational processes - contributed
The company did not have an effective supervision system, allowing the aircraft to be used under inadequate conditions.
1.3 Operational Aspect
1.3.1 Concerning the operation of the aircraft
A) Adverse weather conditions - contributed
The meteorological conditions at the time of the occurrence made it difficult for the crew to locate the aerodrome, causing the aircraft to move away from the approach path to the runway which, added to the drag produced by the unfeathered propeller, aggravated the flight situation, contributing to the forced landing.
B) Coordination of cabin - contributed
The fact that the crew had been searching for the aerodrome, now turning their attention to the passenger who went to the cabin of the aircraft, or turning the attention to the engine failure, caused inattention as to the use of the checklist, resulting in non-compliance and failure to perform prescribed procedures, such as not feathering the left propeller by the propeller lever. This made it difficult to maintain the flight, because the windmilling propeller caused drag, culminating in the forced landing.
C) Pilot trial - contributed
The fact that the commander of the aircraft did not follow the procedures foreseen in the checklist, as suggested by the co-pilot after the engine failure, was decisive for the maintenance of the windmilling propeller, causing a drag that made it difficult to maintain the flight, contributing to forced landing.
D) Maintenance of the aircraft - contributed
The fact that the aircraft operator did not comply with the ANAC guidance related to the left engine condition with the overdue TBO, as well as not having identified the maintenance services performed and defined as not recommended by the manufacturer, contributed that the left engine was operated with the inappropriate governor connection, which resulted in loss of power in flight.
E) Management oversight - contributed
Supervision of aircraft maintenance activities was not adequate, allowing the aircraft to operate with nonconformities and culminating in in-flight engine failure.
1.3.2 Concerning ATS organs
Not contributing.
2 Material Factor
2.1 Concerning the aircraft
Not contributing.
2.2 Concerning equipment and technology systems for ATS
Not contributing.
Accident investigation:
 |
|
Sources:
Piquiatuba Táxi Aéreo
Location
Revision history:
| Date/time | Contributor | Updates |
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