Narrative:
The aircraft struck trees and crashed short of the runway. The final approach was carried out despite the fact that the airport was closed for IFR operations due to fog.
Contributing factors
a. Human Factor
(1). Psychological Aspect
It contributed, since the pilot in command adopted an improvisational attitude through the adoption of unforeseen procedures in the face of the insistence on landing, despite the weather conditions present. A likely channeling of attention to external references may have contributed to the loss of operational performance, leading to the loss of the maintenance condition of the basic flight parameters.
(2). Physiological Aspect
Undetermined since the absence of interference from toxicological factors was not effectively verified.
b. Material Factor
Didn't contribute.
c. Operational Factor
(1). Deficient Instruction
It contributed since there was no periodic simulator training and also no cockpit resource management (CRM) training.
(2). Deficient Supervision
It contributed since there was no adequate monitoring of the circumstances of operation by the Company's operations sector and, also, there were no defined and clear rules and specific operating routines that adequately addressed the various aspects of the operation.
(3). Little Flight or Aircraft Experience
It contributed because of the small experience in the aircraft by the copilot.
(4). Influence of the Environment
It contributed since visibility was limited at the time of the accident.
(5). Deficient Cockpit Coordination
Contributed since there was no briefing to the accomplishment of the descent procedure by instruments, the copilot did not follow the execution of the procedures after the critical point since he concentrated his attention to the search of external references, thus abandoning the monitoring of the flight parameters.
(6). Disabled Infrastructure
Indetermined since the influence of the low accuracy of the NDB on the heading lags occurred in the descent procedure was not perfectly established and no effective test was performed.
(7). Poor Planning
It contributed because there was no briefing in the procedure of descent by instrument and approach lost.
(8). Deficient discipline of Flight
The pilot therefore continued the flight, without visibility, at an altitude below the minimum for this operating condition.
(9). Adverse Weather Conditions
It contributed as the prevailing weather conditions were marginal, with the aerodrome closed for IFR operation.
Controlled Flight Into Terrain (CFIT) - Ground
| Status: | Accident investigation report completed and information captured |
| Date: | Saturday 7 May 1994 |
| Time: | 12:48 |
| Type: |  Embraer EMB-110EJ Bandeirante |
| Operator: | RICO Taxi Aéreo |
| Registration: | PT-GJW |
| MSN: | 110072 |
| First flight: | 1976 |
| Crew: | Fatalities: 0 / Occupants: 2 |
| Passengers: | Fatalities: 0 / Occupants: 14 |
| Total: | Fatalities: 0 / Occupants: 16 |
| Aircraft damage: | Damaged beyond repair |
| Location: | near São Gabriel da Cachoeira Airport, AM (SJL) ( Brazil)
|
| Phase: | Landing (LDG) |
| Nature: | Domestic Non Scheduled Passenger |
| Departure airport: | Santa Isabel do Rio Negro-Tapuruquara Airport, AM (IRZ/SWTP), Brazil |
| São Gabriel da Cachoeira Airport, AM (SJL/SBUA), Brazil |
The aircraft struck trees and crashed short of the runway. The final approach was carried out despite the fact that the airport was closed for IFR operations due to fog.
Probable Cause:
Contributing factors
a. Human Factor
(1). Psychological Aspect
It contributed, since the pilot in command adopted an improvisational attitude through the adoption of unforeseen procedures in the face of the insistence on landing, despite the weather conditions present. A likely channeling of attention to external references may have contributed to the loss of operational performance, leading to the loss of the maintenance condition of the basic flight parameters.
(2). Physiological Aspect
Undetermined since the absence of interference from toxicological factors was not effectively verified.
b. Material Factor
Didn't contribute.
c. Operational Factor
(1). Deficient Instruction
It contributed since there was no periodic simulator training and also no cockpit resource management (CRM) training.
(2). Deficient Supervision
It contributed since there was no adequate monitoring of the circumstances of operation by the Company's operations sector and, also, there were no defined and clear rules and specific operating routines that adequately addressed the various aspects of the operation.
(3). Little Flight or Aircraft Experience
It contributed because of the small experience in the aircraft by the copilot.
(4). Influence of the Environment
It contributed since visibility was limited at the time of the accident.
(5). Deficient Cockpit Coordination
Contributed since there was no briefing to the accomplishment of the descent procedure by instruments, the copilot did not follow the execution of the procedures after the critical point since he concentrated his attention to the search of external references, thus abandoning the monitoring of the flight parameters.
(6). Disabled Infrastructure
Indetermined since the influence of the low accuracy of the NDB on the heading lags occurred in the descent procedure was not perfectly established and no effective test was performed.
(7). Poor Planning
It contributed because there was no briefing in the procedure of descent by instrument and approach lost.
(8). Deficient discipline of Flight
The pilot therefore continued the flight, without visibility, at an altitude below the minimum for this operating condition.
(9). Adverse Weather Conditions
It contributed as the prevailing weather conditions were marginal, with the aerodrome closed for IFR operation.
Accident investigation:
 |
|
Classification:
Controlled Flight Into Terrain (CFIT) - Ground
Photos
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 Santa Isabel do Rio Negro-Tapuruquara Airport, AM to São Gabriel da Cachoeira Airport, AM as the crow flies is 222 km (139 miles).
Distance from Santa Isabel do Rio Negro-Tapuruquara Airport, AM to São Gabriel da Cachoeira Airport, AM as the crow flies is 222 km (139 miles).
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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