Unfallbericht:
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.
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.
| Status: | Accident investigation report completed and information captured |
| Datum: | Montag 11 November 1991 |
| Zeit: | 21:43 |
| Flugzeugtyp: |  Embraer EMB-110P1 Bandeirante |
| Fluggesellschaft: | Nordeste Linhas Aéreas |
| Kennzeichen: | PT-SCU |
| Werknummer: | 110314 |
| Baujahr: | 1980 |
| Betriebsstunden: | 3973 |
| Triebwerk: | 2 Pratt & Whitney Canada PT6A-34 |
| Besatzung: | Todesopfer: 3 / Insassen: 3 |
| Fluggäste: | Todesopfer: 12 / Insassen: 12 |
| Gesamt: | Todesopfer: 15 / Insassen: 15 |
| Opfer am Boden: | Todesopfer: 2 |
| Sachschaden: | Zerstört |
| Konsequenzen: | Written off (damaged beyond repair) |
| Unfallort: | 0,5 km (0.3 Meilen) NE of Recife-Guararapes International Airport, PE (REC) ( Brasilien)
|
| Flugphase: | Anfangssteigflug (ICL) |
| Betriebsart: | Inländischer planmäßiger Passagierflug |
| Flug von: | Recife-Guararapes International Airport, PE (REC/SBRF), Brasilien |
| Salvador-Dois de Julho International Airport, BA (SSA/SBSV), Brasilien | |
| Flugnummer: | 115 |
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.
Accident investigation:
 |
|
Informationsquelle:
» CENIPA - Centro de Investigação e Prevenção de Acidentes AeronáuticosFotos
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.
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.
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
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