ASN logo
Last updated: 16 December 2018
Status:Final
Date:Monday 11 November 1991
Time:21:43
Type:Silhouette image of generic E110 model; specific model in this crash may look slightly different
Embraer EMB-110P1 Bandeirante
Operator:Nordeste Linhas Aéreas
Registration: PT-SCU
C/n / msn: 110314
First flight: 1980
Engines: 2 Pratt & Whitney Canada PT6A-34
Crew:Fatalities: 3 / Occupants: 3
Passengers:Fatalities: 12 / Occupants: 12
Total:Fatalities: 15 / Occupants: 15
Ground casualties:Fatalities: 2
Aircraft damage: Damaged beyond repair
Location:0,5 km (0.3 mls) NE of Recife-Guararapes International Airport, PE (REC) (   Brazil)
Phase: Initial climb (ICL)
Nature:Domestic Scheduled Passenger
Departure airport:Recife-Guararapes International Airport, PE (REC/SBRF), Brazil
Destination airport:Salvador-Dois de Julho International Airport, BA (SSA/SBSV), Brazil
Flightnumber: 115
Narrative:
The Bandeirante was piloted by a DAC check pilot and a co-pilot from Nordeste. During takeoff the right engine suffered a failure. A fire erupted immediately. Takeoff was continued and the airplane rotated after 900 m instead of the usual 570 m. The Bandeirante barely climbed and then another bang was heard. Flaming debris fell from the right hand engine, setting fire to an area within the airport perimeter fence. The airplane climbed to a height of 30 m and yawed to the right. The flight crew applied the wrong technique to counter the yaw. Some thirty seconds after takeoff the aircraft collided with two residences and crashed onto a public square.
It was determined that the temperature indicator for the right hand engine was faulty, displaying a lower than actual temperature. The engine operated for some time at high temperatures because of the faulty system. It was also found that, after completion, some maintenance and inspection tasks were just signed by the maintenance engineer. Signatures from the maintenance inspector were missing.

Probable Cause:

CONCLUSION:

Human Factor - Psychological Aspect - Contributed
At the individual level, the delay in the decision making of the pilots as to the appropriate procedures for that emergency situation. At the organizational level, the lack of adequate training for emergency situations and the absence of activities to prevent aviation accidents in the company.

Material Factor
(1) Project Deficiency - Contributed
The "T5 Bus Bar Assembly" set, specifically the Bus Bar's insulation and fastening system, proved to be deficient. The detachment of their insulation gloves had the double consequence of causing erroneous TIT indication and clogging of the vanes' cooling holes, aggravated by the maintenance aspect.
(2) Manufacturing Deficiency - Contributed
There was a deficiency in the process of casting the compressor turbine stator assembly (CT Vane Ring), generating fins with wall thicknesses different from those predicted in the design.

Operational Factor
(1) Poor Application of Commands - Undetermined
This factor was not fully characterized due to the inexistence of flight data recorders that could confirm their participation. The pilot could have compensated the rudder to the wrong side after the engine failure or the rudder compensator could already be in the wrong compensation to counteract the yaw tendency of the aircraft.
(2) Poor Maintenance - Contributed
Due to the notoriety of the facts and evidence raised in the investigation, there was a failure by the company during the HSI (Hot Section Inspection), when the limits of CT Vane Ring cracks were not observed.
(3) Poor Instruction - Contributed
The company did not meet the minimum requirements for crew members to operate the aircraft properly in emergency situations, as required by RBHA 135.
(4) Poor Supervision - Present and Indeterminate Contribution.
The company did not comply with aviation standards in order to supervise the execution of the maintenance services performed.
(5) Poor Judgment - Contributed
The takeoff could and should have been aborted by the pilot in command.
(6) Influence of the Environment - Undetermined
The take-off was carried out at night time and, considering the particularities of this situation, it was possible that the environment contributed negatively to the pilot's judgment, by choosing to continue the takeoff.

Classification:

Uncontained engine failure
Loss of control

Sources:
» CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos


Photos

Add your photo of this accident or aircraft

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 Recife-Guararapes International Airport, PE to Salvador-Dois de Julho International Airport, BA as the crow flies is 647 km (404 miles).
Accident location: Approximate; accuracy within a few kilometers.

languages: languages

Share

Embraer EMB-110

  • 500 built
  • 47th loss
  • 30th fatal accident
  • 7th worst accident (at the time)
  • 9th worst accident (currently)
» safety profile

 Brazil
  • 55th worst accident (at the time)
  • 63rd worst accident (currently)
» safety profile