Narrative:
A Beechcraft 350 Super King Air was destroyed in an accident at the Terravista Golf Club Airport, Bahia, Brazil. All 14 on board were killed.
The crew took off from São Paulo-Congonhas Airport, SP (CGH) at 18:31, with the Terravista Golf Club Airport (SBTV) as destination.
During the approach for landing at 20:53, amid a heavy rain, the aircraft crashed into a tree about 900 yards from runway 15. After the first collision, the aircraft flew for 700 meters, eventually colliding against other trees and then into the ground
Contributing factors:
1 Human Factor
1.1 Medical Aspect
Nothing to report.
1.2 Psychological Aspect
1.2.1 Individual information
1.2.1.1 Attitude - contributed
The failure of the crew to comply with the prescribed standards and procedures contributed to the occurrence of this accident.
1.2.1.2 Motivation - contributed
High motivation for landing. The pilot did not observe all the critical aspects surrounding the flight situation and proceeded to land under unfavourable conditions.
1.2.1.3 Perception - contributed
The crew, faced with adverse conditions, presented loss of situational awareness, when they did not present the precise perception of the conditions affecting the flight, which may have been influenced by the high motivation to land, hindering the critical analysis.
1.2.1.4 Decision making process - contributed
There was a loss of critical analysis of the situation in this flight, when in the judgment the crew decided to continue the flight to a landing in an uncertain environment.
1.2.2 Psychosocial information
Nothing to report.
1.2.3 Organisational information
1.2.3.1 Organisational Processes - contributed to
The organization did not have a system to monitor the commander's operational performance in order to identify and correct existing malfunctions.
1.3 Operational Aspect
1.3.1 Adverse weather conditions - contributed
Based on the dialogues from the CVR it was possible to verify that, during the descent and while flying over the Terravista Aerodrome, the crew was able to perceive that the field was not operating in visual conditions. Nevertheless, the crew proceeded with the visual procedure.
1.3.2 Deviation from navigation - contributed
The crew requested the cancellation of the instrument flight plan, without in fact being in visual condition and using on-board GPS equipment to carry out an "improvised" IFR procedure during the traffic circuit in the Terravista Airfield.
1) A different visual traffic circuit than that established in the air traffic rules has been established:
2) Excessive speed was used, contrary to the Aircraft Flight Manual;
3) The wind leg was performed at the bow 360, 30 degrees offset to the right of the ideal bow;
4) The wind leg was performed in the NE sector instead of the SW sector, contrary to what was predicted in the ROTAER; and
5) No altitude was maintained in the leg with the wind, having reached 600 feet.
1.3.3 Cabin coordination - contributed
The crew has lost situational awareness of the vertical location (descent slope). The co-pilot possibly trusted and accepted the commander's decisions without contesting them. There was complacency from the co-pilot, probably influenced by his little flying experience, enhanced by the absence of CRM training.
Decisions were made only by the commander based on his own perception, assuming the risk of proceeding to landing without having obtained visual contact with the runway. This fact evidences flaws in the decision-making process.
1.3.4 Trial of pilotage - contributed
The dialogue conducted between the pilots suggests that they obtained visual contact with the track, momentarily, during the performance of the "improvised" GPS procedure. It is observed the failure in this aspect, considering that it was not taken into account that the aerodrome operated below the minimum (VFR), which made it impossible, in fact, the success in concluding the final approach.
1.3.5 Flight planning - contributed
All the necessary meteorological information for planning the flight to the destination was available in the AIS Room before Congonhas took off. Based on a proper analysis of the available meteorological information and taking into account risk management, the crew should have followed the planning established in the flight plan and made the landing at Porto Seguro, instead of driving it to the Terravista Aerodrome, which operated below the minimum (VFR).
1.3.6 Management supervision - undetermined
The pilot played a decisive role in the operational and administrative supervision of the aircraft, as he was delegated the management functions, with autonomy and freedom to make decisions. Thus, the latent failures could not be detected and corrected. This situation possibly contributed to the failure in this respect, since the role of supervisor and executor was in charge of the same person.
1.3.7 Flight discipline - contributed
This aspect was characterized at the time when the crew requested the cancellation of the instrument flight plan, without being completely in visual flight conditions, having nevertheless proceeded with the landing procedure.
1.3.8 Other operational aspects - contributed
There was no record of any in-flight briefing for the approach and landing procedures performed by the commander, failing to define important aspects, such as: type of procedure
Controlled Flight Into Terrain (CFIT) - Ground
METAR 222300Z 20006KT 5000 -RA FEW012 BKN015 BKN050 22/22 Q1020.
| Status: | Accident investigation report completed and information captured |
| Date: | Friday 22 May 2009 |
| Time: | 20:53 |
| Type: |  Beechcraft B300 King Air 350 |
| Operator: | Santa Coloma Investimentos e Participações Ltda. |
| Registration: | PR-MOZ |
| MSN: | FL-237 |
| First flight: | 1999 |
| Total airframe hrs: | 3556 |
| Engines: | 2 Pratt & Whitney Canada PT6A-60A |
| Crew: | Fatalities: 2 / Occupants: 2 |
| Passengers: | Fatalities: 12 / Occupants: 12 |
| Total: | Fatalities: 14 / Occupants: 14 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | Porto Seguro-Terravista Golf Club Airport, BA ( Brazil)
|
| Phase: | Approach (APR) |
| Nature: | Executive |
| Departure airport: | São Paulo-Congonhas Airport, SP (CGH/SBSP), Brazil |
| Porto Seguro-Terravista Golf Club Airport, BA (SBTV), Brazil |
A Beechcraft 350 Super King Air was destroyed in an accident at the Terravista Golf Club Airport, Bahia, Brazil. All 14 on board were killed.
The crew took off from São Paulo-Congonhas Airport, SP (CGH) at 18:31, with the Terravista Golf Club Airport (SBTV) as destination.
During the approach for landing at 20:53, amid a heavy rain, the aircraft crashed into a tree about 900 yards from runway 15. After the first collision, the aircraft flew for 700 meters, eventually colliding against other trees and then into the ground
Probable Cause:
Contributing factors:
1 Human Factor
1.1 Medical Aspect
Nothing to report.
1.2 Psychological Aspect
1.2.1 Individual information
1.2.1.1 Attitude - contributed
The failure of the crew to comply with the prescribed standards and procedures contributed to the occurrence of this accident.
1.2.1.2 Motivation - contributed
High motivation for landing. The pilot did not observe all the critical aspects surrounding the flight situation and proceeded to land under unfavourable conditions.
1.2.1.3 Perception - contributed
The crew, faced with adverse conditions, presented loss of situational awareness, when they did not present the precise perception of the conditions affecting the flight, which may have been influenced by the high motivation to land, hindering the critical analysis.
1.2.1.4 Decision making process - contributed
There was a loss of critical analysis of the situation in this flight, when in the judgment the crew decided to continue the flight to a landing in an uncertain environment.
1.2.2 Psychosocial information
Nothing to report.
1.2.3 Organisational information
1.2.3.1 Organisational Processes - contributed to
The organization did not have a system to monitor the commander's operational performance in order to identify and correct existing malfunctions.
1.3 Operational Aspect
1.3.1 Adverse weather conditions - contributed
Based on the dialogues from the CVR it was possible to verify that, during the descent and while flying over the Terravista Aerodrome, the crew was able to perceive that the field was not operating in visual conditions. Nevertheless, the crew proceeded with the visual procedure.
1.3.2 Deviation from navigation - contributed
The crew requested the cancellation of the instrument flight plan, without in fact being in visual condition and using on-board GPS equipment to carry out an "improvised" IFR procedure during the traffic circuit in the Terravista Airfield.
1) A different visual traffic circuit than that established in the air traffic rules has been established:
2) Excessive speed was used, contrary to the Aircraft Flight Manual;
3) The wind leg was performed at the bow 360, 30 degrees offset to the right of the ideal bow;
4) The wind leg was performed in the NE sector instead of the SW sector, contrary to what was predicted in the ROTAER; and
5) No altitude was maintained in the leg with the wind, having reached 600 feet.
1.3.3 Cabin coordination - contributed
The crew has lost situational awareness of the vertical location (descent slope). The co-pilot possibly trusted and accepted the commander's decisions without contesting them. There was complacency from the co-pilot, probably influenced by his little flying experience, enhanced by the absence of CRM training.
Decisions were made only by the commander based on his own perception, assuming the risk of proceeding to landing without having obtained visual contact with the runway. This fact evidences flaws in the decision-making process.
1.3.4 Trial of pilotage - contributed
The dialogue conducted between the pilots suggests that they obtained visual contact with the track, momentarily, during the performance of the "improvised" GPS procedure. It is observed the failure in this aspect, considering that it was not taken into account that the aerodrome operated below the minimum (VFR), which made it impossible, in fact, the success in concluding the final approach.
1.3.5 Flight planning - contributed
All the necessary meteorological information for planning the flight to the destination was available in the AIS Room before Congonhas took off. Based on a proper analysis of the available meteorological information and taking into account risk management, the crew should have followed the planning established in the flight plan and made the landing at Porto Seguro, instead of driving it to the Terravista Aerodrome, which operated below the minimum (VFR).
1.3.6 Management supervision - undetermined
The pilot played a decisive role in the operational and administrative supervision of the aircraft, as he was delegated the management functions, with autonomy and freedom to make decisions. Thus, the latent failures could not be detected and corrected. This situation possibly contributed to the failure in this respect, since the role of supervisor and executor was in charge of the same person.
1.3.7 Flight discipline - contributed
This aspect was characterized at the time when the crew requested the cancellation of the instrument flight plan, without being completely in visual flight conditions, having nevertheless proceeded with the landing procedure.
1.3.8 Other operational aspects - contributed
There was no record of any in-flight briefing for the approach and landing procedures performed by the commander, failing to define important aspects, such as: type of procedure
Accident investigation:
 |
|
Classification:
VFR flight in IMC Controlled Flight Into Terrain (CFIT) - Ground
Sources:
» CENIPAMETAR Weather report:
23:00 UTC / 20:00 local time:METAR 222300Z 20006KT 5000 -RA FEW012 BKN015 BKN050 22/22 Q1020.
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 São Paulo-Congonhas Airport, SP to Porto Seguro-Terravista Golf Club Airport, BA as the crow flies is 1110 km (694 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from São Paulo-Congonhas Airport, SP to Porto Seguro-Terravista Golf Club Airport, BA as the crow flies is 1110 km (694 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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Beech King Air
- 3550+ built
- 157th loss
- 95th fatal accident
- The worst accident (at the time)
- 2nd worst accident (currently)
Brazil- 77th worst accident (at the time)
- 78th worst accident (currently)
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