Narrative:
Embraer 110 PT-FAW was being readied for a flight from the Fernando De Noronha Archipelago (FEN) to Recife (REC) on the mainland of Brazil. The aircraft had been on the ground for just 30 minutes when the engines were started again. The pre-departure checks were carried out by the first officer, while the captain arrived in a hurry. The aircraft was taxied out immediately and it is presumed that the crew did not carry out the pre-takeoff checklist. The airplane took off from runway 12, entered a steep climb and turned right. Shortly afterwards the airplane was seen to dive into the sea.
Investigation revealed that both pilots had very little experience on Bandeirante planes. Also, they had not flown such a plane in 141 (captain) and 133 days (first officer) days.
CONCLUSION:
Human Factor
(1) Physiological Aspect - Undetermined
There are indications of the contribution of this aspect with regard to the spatial disorientation of the crew.
(2) Psychological Aspect - Contributed
To the extent that the organization was not equipped with effective systems for monitoring and training of personnel.
Operational Factor
(1). Deficient Instruction - Contributed
For qualitative and quantitative deficiency of instruction, not attributing technical conditions necessary for the performance of the air activity.
(2). Deficient Maintenance - Contributed
The inadequacy of the corrective services performed on the aircraft.
(3). Deficient Application in the Command - Contributed
For the crew's ineptitude to allow the aircraft to engage in abnormal behavior.
(4). Deficient Cockpit Co-ordination - Contributed
The inadequate use of cockpit resources for the operation of the aircraft, and also failure to comply with operational standards.
(5). Influence of the Environment - Contributed
By the intrinsic characteristic of Fernando de Noronha aerodrome, as capable of causing spatial disorientation.
(6). Deficient - contributed
The inadequate assessment of certain operational aspects during the mission and the use of own piloting standards
(7). Little Flight Experience in the Aircraft - Contributed
For the reduced average of 44:00h of flight for the pilot and 73:00h for the co-pilot and, also, the crew leave for more than 120 days of air activity.
(8). Deficient Supervision - Contributed
The lack of supervision of the Air Transport Division in relation to planning and operational maintenance of its pilots, creating an undesirable climate of complacency in the organization.
(9). Other Operational Aspects - Contributed
By the intentional and unnecessary increase of the risk margin, when the pilots are not properly readapted, provided for in the RBHA-61, leaving the crew disqualified for the mission.
Loss of control
| Status: | Accident investigation report completed and information captured |
| Date: | Thursday 20 September 1990 |
| Time: | 19:40 |
| Type: |  Embraer EMB-110P1 Bandeirante |
| Operator: | Governo do Estado de Pernambuco |
| Registration: | PT-FAW |
| MSN: | 110368 |
| First flight: | 1982 |
| Engines: | 2 Pratt & Whitney Canada PT6A-34 |
| Crew: | Fatalities: 2 / Occupants: 2 |
| Passengers: | Fatalities: 10 / Occupants: 10 |
| Total: | Fatalities: 12 / Occupants: 12 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | off Fernando de Noronha Airport, FN (FEN) ( Brazil)
|
| Phase: | Initial climb (ICL) |
| Nature: | Domestic Scheduled Passenger |
| Departure airport: | Fernando de Noronha Airport, FN (FEN/SBFN), Brazil |
| Recife-Guararapes International Airport, PE (REC/SBRF), Brazil |
Embraer 110 PT-FAW was being readied for a flight from the Fernando De Noronha Archipelago (FEN) to Recife (REC) on the mainland of Brazil. The aircraft had been on the ground for just 30 minutes when the engines were started again. The pre-departure checks were carried out by the first officer, while the captain arrived in a hurry. The aircraft was taxied out immediately and it is presumed that the crew did not carry out the pre-takeoff checklist. The airplane took off from runway 12, entered a steep climb and turned right. Shortly afterwards the airplane was seen to dive into the sea.
Investigation revealed that both pilots had very little experience on Bandeirante planes. Also, they had not flown such a plane in 141 (captain) and 133 days (first officer) days.
Probable Cause:
CONCLUSION:
Human Factor
(1) Physiological Aspect - Undetermined
There are indications of the contribution of this aspect with regard to the spatial disorientation of the crew.
(2) Psychological Aspect - Contributed
To the extent that the organization was not equipped with effective systems for monitoring and training of personnel.
Operational Factor
(1). Deficient Instruction - Contributed
For qualitative and quantitative deficiency of instruction, not attributing technical conditions necessary for the performance of the air activity.
(2). Deficient Maintenance - Contributed
The inadequacy of the corrective services performed on the aircraft.
(3). Deficient Application in the Command - Contributed
For the crew's ineptitude to allow the aircraft to engage in abnormal behavior.
(4). Deficient Cockpit Co-ordination - Contributed
The inadequate use of cockpit resources for the operation of the aircraft, and also failure to comply with operational standards.
(5). Influence of the Environment - Contributed
By the intrinsic characteristic of Fernando de Noronha aerodrome, as capable of causing spatial disorientation.
(6). Deficient - contributed
The inadequate assessment of certain operational aspects during the mission and the use of own piloting standards
(7). Little Flight Experience in the Aircraft - Contributed
For the reduced average of 44:00h of flight for the pilot and 73:00h for the co-pilot and, also, the crew leave for more than 120 days of air activity.
(8). Deficient Supervision - Contributed
The lack of supervision of the Air Transport Division in relation to planning and operational maintenance of its pilots, creating an undesirable climate of complacency in the organization.
(9). Other Operational Aspects - Contributed
By the intentional and unnecessary increase of the risk margin, when the pilots are not properly readapted, provided for in the RBHA-61, leaving the crew disqualified for the mission.
Accident investigation:
 |
|
Classification:
Flightcrew un(der)qualifiedLoss of control
Sources:
» CENIPA - Centro de Investigação e Prevenção de Acidentes AeronáuticosPhotos
Map
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 Fernando de Noronha Airport, FN to Recife-Guararapes International Airport, PE as the crow flies is 547 km (342 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from Fernando de Noronha Airport, FN to Recife-Guararapes International Airport, PE as the crow flies is 547 km (342 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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Embraer EMB-110
- 500 built
- 43rd loss
- 29th fatal accident
- 14th worst accident (at the time)
- 21st worst accident (currently)
Brazil- 76th worst accident (at the time)
- 88th worst accident (currently)
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