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Last updated: 22 October 2021
Status:Definitief
Datum:zaterdag 14 september 2002
Tijd:05:40
Type:Silhouette image of generic AT43 model; specific model in this crash may look slightly different
ATR 42-312
Luchtvaartmaatschappij:TOTAL Linhas Aéreas
Registratie: PT-MTS
Constructienummer: 026
Bouwjaar: 1986
Aantal vlieguren:33371
Aantal vluchten:22922
Motoren: 2 Pratt & Whitney Canada PW120
Bemanning:slachtoffers: 2 / inzittenden: 2
Passagiers:slachtoffers: 0 / inzittenden: 0
Totaal:slachtoffers: 2 / inzittenden: 2
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:38 km (23.8 mijl) S of Paranapanema, SP (   Brazilië)
Fase: Kruisvlucht (ENR)
Soort vlucht:Vracht
Vliegveld van vertrek:São Paulo-Guarulhos International Airport, SP (GRU/SBGR), Brazilië
Vliegveld van aankomst:Londrina Airport, PR (LDB/SBLO), Brazilië
Vluchtnummer:5561
Beschrijving:
An ATR-42 cargo plane was destroyed when it crashed near Paranapanema, SP, Brazil. Both crew members were killed.
TOTAL Linhas Aéreas Flight 5561, departed São Paulo-Guarulhos (GRU) at 04:52 on a domestic flight to Londrina Airport, PR (LDB). The ATR climbed to FL180 and the flight progressed uneventful until 05:37. At that time the autopilot disconnected. The crew faced an elevator pitch trim runaway. There was no emergency checklist available for this situation. Also, the pilots rarely received training for an event like this. The captain instructed the copilot to pull a specific circuit breaker. The copilot initially did not understand this instructions but later complied. Two seconds later the Vmo (maximum operating speed) alarm sounded and engine power was reduced to 10%.
The crew attempted to re-establish level flight but failed. The airplane descended out of control and struck the ground at a speed of 366 knots.

The ATR-42 departed São Paulo at 04:40 in the morning for a mail flight to Londrina and climbed to its cruising altitude of FL180. Twenty minutes later the
airplane crashed in a field near Paranapanema.

Probable Cause:

PROBABLE CAUSE:
1. Human Factors
Psychological aspect - Contributing factor
The pilots' perception about the situation was affected by lack of specific training and procedures, which, coupled with the limited time available for action and lack of clarity in communications, influenced the time elapsed for taking corrective actions.
Operational Aspect
a) Coordination Cabin - Contributed
Communication between the crew was not clear at the time of emergency, making the co-pilot did not understand at first, the action to be performed, which increased the time spent to disarm the CB. Such facts, however, can not be separated from the situation experienced by pilots with inadequate training for emergency and in a short time to identify the problem and take the corrective actions.
b) Supervision - Undetermined
The company had not provided a regular CRM training to pilots. Furthermore, the captain did not receive simulator training for over one year. It was impossible to determine, however, if the regular training and updating of the CRM simulator training of the pilot would have prevented the accident.
c) Other Operational Issues - Undetermined
The removal of the pilot from his seat at the time of the emergency may have increased the time spent in identifying the crash and taking corrective actions, but it was not possible to establish whether the accident would be avoided if he would have been in the cockpit.
The co-pilot was slow to understand the situation and initiate corrective actions, although the alarm "whooler" has sounded, also increasing the elapsed time.

2. Material Factor
a) Project - Contributed
The operational testing under J IC 27-32-00 allowed the partial completion of the procedures due to lack of clarity, which allowed the release of the aircraft for flight with a defective relay.
Furthermore, although the elevator trim system has been certified, no procedure for emergency triggering of the compensator in the manuals provided by the manufacturer, no replacement intervals of the components of the elevator trim system in "Time Limits" systems normal and reserves were not independent and the system had a low tolerance for errors.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 4 years and 7 months
Accident number: A-006/CENIPA/2007
Download report: Final report

Bronnen:
» Agência Estado
» ICAO Adrep


Veiligheidsmaatregelen
On March 5, 2003, DGAC France issued Airworthiness Directive AD 2003-106(B), requiring an inspection and replacement (if needed) of the protective guard of the stand by pitch trim switch (18CG), installed on the centre pedestal.
In some cases, the AD states, a damaged protective guard, although engaged, may not prevent an inadvertent activation of the stand by pitch trim.

Foto's

photo of ATR-42-312-PT-MTS
accident date: 14-09-2002
type: ATR 42-312
registration: PT-MTS
photo of ATR-42-312-F-OGNE
accident date: 14-09-2002
type: ATR 42-312
registration: F-OGNE
 

Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen São Paulo-Guarulhos International Airport, SP en Londrina Airport, PR bedraagt 474 km (296 miles).
Accident location: Exact; deduced from official accident report.

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.
languages: languages

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