Narrative:The Embraer Brasilia landed at Manaus-Eduardo Gomes International Airport in Brazil and taxied to the platform. The flight crew feathered the propellers and applied the brakes as they wanted to stop the aircraft. There was no deceleration after both captain and co-pilot used the brakes. The co-pilot suggested to use reverse thrust, but the propellers were already feathered.
In an attempt to avoid impact against a building ahead, the pilot turned the aircraft to the left. The emergency brake was applied; however, by that time the aircraft collided with another brick building. On impact, the left propeller and engine were damage, and the right landing gear fell into a drainage ditch, approximately one meter deep.
All occupants were unhurt.
Probable Cause:
1 Human Factor
Operational Aspect
a. Training - Contributed
The crew did not have sufficient training to enable the desired assertiveness for the correct use of aircraft resources, which would probably have prevented the accident, since, instead of applying the emergency brake, they applied reverse with the feathered props, contrary to the procedure provided for in the Aircraft Manual.
b. Maintenance - Contributed
The maintenance services were not efficient, as they did not comply with the Aircraft Maintenance Manual in relation to the dimensional adjustment of the Hub Cap Drive Clips' drive clips, and the Service Bulletin incorporated stickers to the outer doors of the main landing gear, as a reminder to the mechanic to check the clearances.
c. Application of the Commands - Contributed
The co-pilot failed to apply the reverse pitch on the propellers as they were feathered, and at that moment the emergency brake should be commanded to brake the aircraft.
d. Supervision - Contributed
The company failed to adequately check the execution of the actions provided for in the Aircraft Maintenance Manual regarding the "Anti-Skid" system and to verify the application of all service bulletins issued by the manufacturer.
2 Material Factor
Did not contribute.
Accident investigation:
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Investigating agency: | CENIPA Brazil |
Status: | Investigation completed |
Duration: | 6 years and 6 months | Accident number: | RF A-004/CENIPA/2009 | Download report: | Final report
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Classification:
Failure to follow AD and SB's
Damaged on the ground
Follow-up / safety actions
CENIPA issued 3 Safety Recommendations
DAC issued 4 Safety Recommendations
Issued: 04-NOV-2004 | To: Rico Linhas Aéreas | RSV (A) 195/A/2004 |
Deverá incorporar os capítulos do Manual de Manutenção e o Boletim de Serviço relacionados à inspeção dos clips de acionamento dos sensores de velocidade. |
Issued: 04-NOV-2004 | To: Rico Linhas Aéreas | RSV (A) 196/A/2004 |
Deverá orientar a área de manutenção para observar os limites de tolerância das folgas do sistema anti-skid. |
Issued: 04-NOV-2004 | To: Rico Linhas Aéreas | RSV (A) 197/A/2004 |
Deverá providenciar um refreshment para os seus tripulantes técnicos, com o objetivo de atualizá-los sobre procedimentos básicos de operação do EMB-120. |
Issued: 04-NOV-2004 | To: DIPAA | RSV (A) 198/A/2004 |
Deverá, em seu Programa de Trabalho Anual, programar Vistorias de Segurança de Vôo periódicas na Empresa Rico Linhas Aéreas S/A, com o objetivo de avaliar o cumprimento do PPAA. |
Issued: 01-JUL-2009 | To: GERÊNCIA-7 | RSO (A) 84/A/2009 - CENIPA |
Notificar a empresa RICO LINHAS AÉREAS S/A para divulgar o conteúdo deste Relatório Final, através do seu ASV, para todos os funcionários do quadro de pilotos da empresa, enfatizando a necessidade do uso do freio de emergência em caso de falha dos freios normais, e do fiel cumprimento dos procedimentos de emergência constantes dos manuais da aeronave. |
Issued: 01-JUL-2009 | To: GERÊNCIA-7 | RSO 82/A/2009 - CENIPA |
Notificar a empresa RICO LINHAS AÉREAS S/A, para inserir no seu programa de treinamento provas periódicas de Instrução Técnica da aeronave e de Procedimentos de Emergência, a fim de manter o conhecimento básico da aeronave. |
Issued: 01-JUL-2009 | To: GERÊNCIA-7 | RSO 83/A/2009 - CENIPA |
Notificar a empresa RICO LINHAS AÉREAS S/A para viabilizar o treinamento deste tipo de pane em simulador de vôo da aeronave. |
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Photos
accident date:
13-08-2002type: Embraer 120RT Brasilia
registration: PT-SIH
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 Humaitá Airport, AM to Manaus-Eduardo Gomes International Airport, AM as the crow flies is 599 km (374 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.