Narrative:
Pantanal flight 126 departed Campo Grande (CGR) for a 2 hours and 15 min. flight to Vilhena (BVH). The captain was an instructor, the copilot was receiving line training. The copilot was Pilot Flying (PF). While approaching Vilhena, the weather was reported below minima. Instead of diverting to the alternate airport, the captain decided they should execute an Echo 1 arrival procedure, which was an NDB approach to runway 03. Because actual weather at Vilhena had differed from reported weather conditions in the past, they would descend to MDA. If the runway was not in sight at that point, the approach would be aborted. The copilot inserted an MDA of 2500 feet in the Altitude Alert System. This was an error since the MDA was actually 2560 feet. Both pilot did not notice the error. The instructor told the copilot to monitor the artificial horizon during the final stages of the approach. The copilot focused on the artificial horizon and did not monitor the altimeter. The captain tried to obtain visual contact with the ground, but the city lights were off due to lack of electric energy. He did not call out the altitudes and the airplane did not level off at 2500 feet. The copilot probably shut off or silenced the Altitude Alert System and the airplane continued to descend below MDA. The airplane collided with various trees located to the right and one kilometre short of runway 03. It collided with the ground and skidded to a stop. A fire erupted in the no. 1 engine, spreading to the rest of the airplane. All occupants managed to escape.
CONCLUSÃO
Fator Humano - Aspecto Psicológico - Contribuiu
Houve a participação de variáveis psicológicas em nível individual, psicossocial e organizacional que interferiram no desempenho dos tripulantes.
Fator Operacional
(1). Deficiente Coordenação de Cabine - Contribuiu
Houve distribuição desordenada de tarefas na cabine, com inversão de atribuições e canalização de atenção por parte dos dois pilotos.
(2). Condições Meteorológicas Adversas - Contribuíram
O aeródromo estava fechado para operações por instrumentos e havia forte nevoeiro na região do acidente (setor de aproximação).
(3). Deficiente Aplicação de Comando - Indeterminado
O aluno estava realizando procedimento de descida por instrumentos utilizando o piloto automático e, possivelmente, comandou o desacoplamento deste, fazendo com que a aeronave descesse além da altitude selecionada no Altitude Select.
(4). Indisciplina de Vôo - Contribuiu
A tripulação descumpriu intencionalmente regras de tráfego aéreo previstas no RBHA 121, quando da realização de procedimento de descida com o aeródromo operando abaixo dos mínimos previstos.
(5). Deficiente Julgamento - Contribuiu
Houve erro cometido pela tripulação, decorrente da inadequada avaliação das condições operacionais para a realização do procedimento de descida.
(6). Influência do Meio Ambiente - Contribuiu
Houve interferência do ambiente físico externo à cabine, com relação à falta de energia elétrica na cidade. Os pilotos esperavam encontrar luzes da cidade, no entanto, a falta de energia elétrica causou uma errada sensação de posicionamento espacial.
(7). Deficiente Planejamento - Contribuiu
Houve erro cometido pela tripulação, em decorrência de não ter planejado adequadamente a fase de aproximação para pouso.
| Status: | Accident investigation report completed and information captured |
| Date: | Monday 3 March 1997 |
| Time: | 00:44 |
| Type: |  Embraer EMB-120RT Brasilia |
| Operator: | Pantanal Linhas Aéreas Sul-Matogrossenses |
| Registration: | PT-MFC |
| MSN: | 120206 |
| First flight: | 1990 |
| Engines: | 2 Pratt & Whitney Canada PW118 |
| Crew: | Fatalities: 0 / Occupants: 3 |
| Passengers: | Fatalities: 0 / Occupants: 13 |
| Total: | Fatalities: 0 / Occupants: 16 |
| Aircraft damage: | Damaged beyond repair |
| Location: | Vilhena Airport, RO (BVH) ( Brazil)
|
| Phase: | Landing (LDG) |
| Nature: | Domestic Scheduled Passenger |
| Departure airport: | Campo Grande Internacional Airport, MS (CGR/SBCG), Brazil |
| Vilhena Airport, RO (BVH/SBVH), Brazil | |
| Flightnumber: | 126 |
Pantanal flight 126 departed Campo Grande (CGR) for a 2 hours and 15 min. flight to Vilhena (BVH). The captain was an instructor, the copilot was receiving line training. The copilot was Pilot Flying (PF). While approaching Vilhena, the weather was reported below minima. Instead of diverting to the alternate airport, the captain decided they should execute an Echo 1 arrival procedure, which was an NDB approach to runway 03. Because actual weather at Vilhena had differed from reported weather conditions in the past, they would descend to MDA. If the runway was not in sight at that point, the approach would be aborted. The copilot inserted an MDA of 2500 feet in the Altitude Alert System. This was an error since the MDA was actually 2560 feet. Both pilot did not notice the error. The instructor told the copilot to monitor the artificial horizon during the final stages of the approach. The copilot focused on the artificial horizon and did not monitor the altimeter. The captain tried to obtain visual contact with the ground, but the city lights were off due to lack of electric energy. He did not call out the altitudes and the airplane did not level off at 2500 feet. The copilot probably shut off or silenced the Altitude Alert System and the airplane continued to descend below MDA. The airplane collided with various trees located to the right and one kilometre short of runway 03. It collided with the ground and skidded to a stop. A fire erupted in the no. 1 engine, spreading to the rest of the airplane. All occupants managed to escape.
Probable Cause:
CONCLUSÃO
Fator Humano - Aspecto Psicológico - Contribuiu
Houve a participação de variáveis psicológicas em nível individual, psicossocial e organizacional que interferiram no desempenho dos tripulantes.
Fator Operacional
(1). Deficiente Coordenação de Cabine - Contribuiu
Houve distribuição desordenada de tarefas na cabine, com inversão de atribuições e canalização de atenção por parte dos dois pilotos.
(2). Condições Meteorológicas Adversas - Contribuíram
O aeródromo estava fechado para operações por instrumentos e havia forte nevoeiro na região do acidente (setor de aproximação).
(3). Deficiente Aplicação de Comando - Indeterminado
O aluno estava realizando procedimento de descida por instrumentos utilizando o piloto automático e, possivelmente, comandou o desacoplamento deste, fazendo com que a aeronave descesse além da altitude selecionada no Altitude Select.
(4). Indisciplina de Vôo - Contribuiu
A tripulação descumpriu intencionalmente regras de tráfego aéreo previstas no RBHA 121, quando da realização de procedimento de descida com o aeródromo operando abaixo dos mínimos previstos.
(5). Deficiente Julgamento - Contribuiu
Houve erro cometido pela tripulação, decorrente da inadequada avaliação das condições operacionais para a realização do procedimento de descida.
(6). Influência do Meio Ambiente - Contribuiu
Houve interferência do ambiente físico externo à cabine, com relação à falta de energia elétrica na cidade. Os pilotos esperavam encontrar luzes da cidade, no entanto, a falta de energia elétrica causou uma errada sensação de posicionamento espacial.
(7). Deficiente Planejamento - Contribuiu
Houve erro cometido pela tripulação, em decorrência de não ter planejado adequadamente a fase de aproximação para pouso.
Accident investigation:
 |
|
Classification:
Controlled Flight Into Terrain (CFIT) - Ground
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 Campo Grande Internacional Airport, MS to Vilhena Airport, RO as the crow flies is 1036 km (647 miles).
Distance from Campo Grande Internacional Airport, MS to Vilhena Airport, RO as the crow flies is 1036 km (647 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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