Narrative:
An EMB-110 Bandeirante turboprop plane was damaged in an off-airport landing near Cascavel Airport, PR (CAC), Brazil. Both pilots escaped unhurt.
The airplane operated on a cargo flight from Sorocaba Airport to Cascavel. Weather at the destination was poor with limited visibility in fog and a 100 ft overcast. The crew attempted to land, but touched down in a soy bean field about 700 m from the runway 33 threshold. The airplane traveled about 150 meters before coming to rest on its belly.
The only navigational aid available at Cascavel is NDB.
Contributing Factors
1 Human Factor
1.1 Medical Aspect
a) Fatigue - undetermined
It is probable that fatigue occurred, considering that the day before the accident, the crew performed a journey longer than 24 hours, which would be 16 hours, taking into account the type of crew, as well as the rest time.
b) Visual illusions - contributed
It is possible that the crew landed before the runway due to false sensory impressions generated by the dark environment surrounding the aerodrome and the low visibility conditions at the time of the accident (black hole effect).
1.2 Psychological Aspect
1.2.1 Individual Information
a) Attitude - contributed
Excessive self-confidence in equipment and mission influenced the takeoff of Sorocaba in weather conditions unfavorable to landing in Cascavel.
b) Motivation - contributed
The pilot demonstrated to be adapted to the work environment and the flight routine, however he showed a high motivation to fulfill the mission as it was programmed, in order to cause the minimum of interference in the aerial programming of the company.
(c) Decision-making - contributed
The pilots operated at night, a condition that in itself modifies visual perception, although the pilot in command was adapted to routine and recognized that their cognitive abilities could be diminished. In addition, the flight was accompanied by difficulties, such as adverse weather conditions, making it difficult to see and to process information. These conditions added to the stress of the situation compromised the judgment and the decision.
1.2.2 Psychosocial Information
a) Team dynamics - contributed
The aircraft commander did not request the support of the co-pilot to carry out the descent procedure, took over the operation and intended to make the landing, despite the weather. The co-pilot, being inexperienced, trusted the commander and did not interfere, despite realizing the dangerous conditions.
1.2.3 Organizational Information
a) Physical conditions of work - indeterminate
Work shifts that generate changes in routines very often require the need for constant physiological adaptations. This condition can lead to the development of fatigue, creating favorable conditions for human error.
b) Organizational culture - contributed
Flexibility is observed with respect to compliance with flight rules, with low levels of knowledge and application of flight safety strategies. The company was compliant with the changes in operating procedures.
c) Training, Training and Training - contributed
There was a fragile process of training and qualification of new pilots, with deficient monitoring of personnel and the use of missions to train the crew.
d) Organization of work - indeterminate
The aerial activity of the company consisted in the service to fixed clients, being important the conservation of the routines of work, to well serve the users. This caused that changes in the meteorological conditions generated much disorder, since the routes had to be altered, generating costs and time. The crew, on the other hand, probably tried to minimize the interpretation of the adversities in order to force the execution of the planned activity.
e) Organizational processes - undetermined
There may have been a lack of continuous supervision of the aerial activity of the different flights underway.
1.3 Operational Aspect
1.3.1 Concerning the operation of the aircraft
a) Coordination of cabin - contributed
It became evident that communication between the crew was compromised by inadequate management of the tasks assigned to each one, probably due to the difference between the high experience of the pilot in command and the lack of experience of the co-pilot.
b) Flight Discipline - contributed
The crew intentionally violated operational rules, regulations and air traffic regulations without any justification for doing so.
c) Influence of the environment - undetermined
The region near the threshold of runway 33 had visibility-limiting environmental conditions, as it was an area of low demographic density, almost unlit, on a dark, cloud-covered night, which may have contributed to a loss of ramp reference in the final approach.
d) Instruction - contributed
The co-pilot had not yet completed the local flight phase envisaged in the company's training program. The co-driver's only instruction sheet was completed without detailing the exercises performed.
The operational elevation of the company pilots was being performed based on the informality of the flight instructor's observations.
e) Flight planning - contributed
The crew did not adequately prepare the flight because there was no positive prediction of improved weather conditions, which led to them attempting to land in conditions below the minimum IFR.
f) Little pilot experience - contributed
The co-pilot had performed only 01 local flight provided for in the training program of the EMB-110 aircraft and had 1000 total flight hours and only 15 hours and 40 minutes in the aircraft model, which contributed to ineffective pilot advice.
g) Management oversight - contributed
There was poor managerial oversight of the company's management, as well as failing to complete the co-pilot's training program, failed to oversee and monitor flight planning and did not realize that the crew had extrapolated the workday limit.
h) Other - contributed
The crew failed to report to the Radio Station the positions regarding the phases of the IFR procedure it was conducting, contrary to what was foreseen in ICA 100-12.
1.3.2 Concerning ATS organs
It did not.
2 Material Factor
2.1 Concerning the aircraft
It did not.
2.2 Concerning equipment and technology systems for ATS
It did not.
» Edson Dantas
SBCA 190800Z 33015KT 1200 -DZ BR PRFG OVC001 08/08 Q1014=
Wind 330 degrees at 15 knots; visibility 1200m; light drizzle, mist, partial fog; overcast at 100 ft; temperature 8°C, dew point 8°C; 1014 hPa09:00 UTC / 06:00 local time:
SBCA 190900Z 32012KT 2000 -DZ BR PRFG OVC001 08/08 Q1014=
Wind 320 degrees at 12 knots; visibility 2000m; light drizzle, mist, partial fog; overcast at 100 ft; temperature 8°C, dew point 8°C; 1014 hPa
accident date: 19-05-2010
type: Embraer 110P Bandeirante
registration: PT-GKQ
| Status: | Accident investigation report completed and information captured |
| Date: | Wednesday 19 May 2010 |
| Time: | 05:10 |
| Type: |  Embraer EMB-110P Bandeirante |
| Operator: | Táxi Aéreo Weiss |
| Registration: | PT-GKQ |
| MSN: | 110125 |
| First flight: | 1976 |
| Engines: | 2 Pratt & Whitney Canada PT6A-27 |
| Crew: | Fatalities: 0 / Occupants: 2 |
| Passengers: | Fatalities: 0 / Occupants: 0 |
| Total: | Fatalities: 0 / Occupants: 2 |
| Aircraft damage: | Substantial |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | 0,7 km (0.4 mls) from Cascavel Airport, PR (CAC) ( Brazil)
|
| Phase: | Landing (LDG) |
| Nature: | Cargo |
| Departure airport: | Sorocaba Airport, SP (SOD/SDCO), Brazil |
| Cascavel Airport, PR (CAC/SBCA), Brazil |
An EMB-110 Bandeirante turboprop plane was damaged in an off-airport landing near Cascavel Airport, PR (CAC), Brazil. Both pilots escaped unhurt.
The airplane operated on a cargo flight from Sorocaba Airport to Cascavel. Weather at the destination was poor with limited visibility in fog and a 100 ft overcast. The crew attempted to land, but touched down in a soy bean field about 700 m from the runway 33 threshold. The airplane traveled about 150 meters before coming to rest on its belly.
The only navigational aid available at Cascavel is NDB.
Probable Cause:
Contributing Factors
1 Human Factor
1.1 Medical Aspect
a) Fatigue - undetermined
It is probable that fatigue occurred, considering that the day before the accident, the crew performed a journey longer than 24 hours, which would be 16 hours, taking into account the type of crew, as well as the rest time.
b) Visual illusions - contributed
It is possible that the crew landed before the runway due to false sensory impressions generated by the dark environment surrounding the aerodrome and the low visibility conditions at the time of the accident (black hole effect).
1.2 Psychological Aspect
1.2.1 Individual Information
a) Attitude - contributed
Excessive self-confidence in equipment and mission influenced the takeoff of Sorocaba in weather conditions unfavorable to landing in Cascavel.
b) Motivation - contributed
The pilot demonstrated to be adapted to the work environment and the flight routine, however he showed a high motivation to fulfill the mission as it was programmed, in order to cause the minimum of interference in the aerial programming of the company.
(c) Decision-making - contributed
The pilots operated at night, a condition that in itself modifies visual perception, although the pilot in command was adapted to routine and recognized that their cognitive abilities could be diminished. In addition, the flight was accompanied by difficulties, such as adverse weather conditions, making it difficult to see and to process information. These conditions added to the stress of the situation compromised the judgment and the decision.
1.2.2 Psychosocial Information
a) Team dynamics - contributed
The aircraft commander did not request the support of the co-pilot to carry out the descent procedure, took over the operation and intended to make the landing, despite the weather. The co-pilot, being inexperienced, trusted the commander and did not interfere, despite realizing the dangerous conditions.
1.2.3 Organizational Information
a) Physical conditions of work - indeterminate
Work shifts that generate changes in routines very often require the need for constant physiological adaptations. This condition can lead to the development of fatigue, creating favorable conditions for human error.
b) Organizational culture - contributed
Flexibility is observed with respect to compliance with flight rules, with low levels of knowledge and application of flight safety strategies. The company was compliant with the changes in operating procedures.
c) Training, Training and Training - contributed
There was a fragile process of training and qualification of new pilots, with deficient monitoring of personnel and the use of missions to train the crew.
d) Organization of work - indeterminate
The aerial activity of the company consisted in the service to fixed clients, being important the conservation of the routines of work, to well serve the users. This caused that changes in the meteorological conditions generated much disorder, since the routes had to be altered, generating costs and time. The crew, on the other hand, probably tried to minimize the interpretation of the adversities in order to force the execution of the planned activity.
e) Organizational processes - undetermined
There may have been a lack of continuous supervision of the aerial activity of the different flights underway.
1.3 Operational Aspect
1.3.1 Concerning the operation of the aircraft
a) Coordination of cabin - contributed
It became evident that communication between the crew was compromised by inadequate management of the tasks assigned to each one, probably due to the difference between the high experience of the pilot in command and the lack of experience of the co-pilot.
b) Flight Discipline - contributed
The crew intentionally violated operational rules, regulations and air traffic regulations without any justification for doing so.
c) Influence of the environment - undetermined
The region near the threshold of runway 33 had visibility-limiting environmental conditions, as it was an area of low demographic density, almost unlit, on a dark, cloud-covered night, which may have contributed to a loss of ramp reference in the final approach.
d) Instruction - contributed
The co-pilot had not yet completed the local flight phase envisaged in the company's training program. The co-driver's only instruction sheet was completed without detailing the exercises performed.
The operational elevation of the company pilots was being performed based on the informality of the flight instructor's observations.
e) Flight planning - contributed
The crew did not adequately prepare the flight because there was no positive prediction of improved weather conditions, which led to them attempting to land in conditions below the minimum IFR.
f) Little pilot experience - contributed
The co-pilot had performed only 01 local flight provided for in the training program of the EMB-110 aircraft and had 1000 total flight hours and only 15 hours and 40 minutes in the aircraft model, which contributed to ineffective pilot advice.
g) Management oversight - contributed
There was poor managerial oversight of the company's management, as well as failing to complete the co-pilot's training program, failed to oversee and monitor flight planning and did not realize that the crew had extrapolated the workday limit.
h) Other - contributed
The crew failed to report to the Radio Station the positions regarding the phases of the IFR procedure it was conducting, contrary to what was foreseen in ICA 100-12.
1.3.2 Concerning ATS organs
It did not.
2 Material Factor
2.1 Concerning the aircraft
It did not.
2.2 Concerning equipment and technology systems for ATS
It did not.
Accident investigation:
 |
|
Classification:
Controlled Flight Into Terrain (CFIT) - Ground
Sources:
» Avião tenta pousar em aeroporto fechado e acaba em fazenda em Cascavel (PR) (Folha Online)» Edson Dantas
METAR Weather report:
08:00 UTC / 05:00 local time:SBCA 190800Z 33015KT 1200 -DZ BR PRFG OVC001 08/08 Q1014=
Wind 330 degrees at 15 knots; visibility 1200m; light drizzle, mist, partial fog; overcast at 100 ft; temperature 8°C, dew point 8°C; 1014 hPa09:00 UTC / 06:00 local time:
SBCA 190900Z 32012KT 2000 -DZ BR PRFG OVC001 08/08 Q1014=
Wind 320 degrees at 12 knots; visibility 2000m; light drizzle, mist, partial fog; overcast at 100 ft; temperature 8°C, dew point 8°C; 1014 hPa
Photos
accident date: 19-05-2010
type: Embraer 110P Bandeirante
registration: PT-GKQ
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 Sorocaba Airport, SP to Cascavel Airport, PR as the crow flies is 630 km (394 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from Sorocaba Airport, SP to Cascavel Airport, PR as the crow flies is 630 km (394 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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