Accident Embraer EMB-110P Bandeirante PT-GKQ, Wednesday 19 May 2010
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Date:Wednesday 19 May 2010
Time:05:10
Type:Silhouette image of generic E110 model; specific model in this crash may look slightly different    
Embraer EMB-110P Bandeirante
Owner/operator:Táxi Aéreo Weiss
Registration: PT-GKQ
MSN: 110125
Year of manufacture:1976
Engine model:Pratt & Whitney Canada PT6A-27
Fatalities:Fatalities: 0 / Occupants: 2
Other fatalities:0
Aircraft damage: Substantial, written off
Category:Accident
Location:0,7 km from Cascavel Airport, PR (CAC) -   Brazil
Phase: Landing
Nature:Cargo
Departure airport:Sorocaba Airport, SP (SOD/SDCO)
Destination airport:Cascavel Airport, PR (CAC/SBCA)
Investigating agency: CENIPA
Confidence Rating: Accident investigation report completed and information captured
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 unl

METAR:

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 hPa

09:00 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 investigation:
cover
  
Investigating agency: CENIPA
Report number: A - 034/CENIPA/2012
Status: Investigation completed
Duration: 1 year and 10 months
Download report: Final report

Sources:

Avião tenta pousar em aeroporto fechado e acaba em fazenda em Cascavel (PR) (Folha Online)
Edson Dantas

Location

Images:


photo (c) via Werner Fischdick; Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ); January 1979

Revision history:

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