ASN Wikibase Occurrence # 321605
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| Date: | Sunday 23 November 2008 |
| Time: | 11:15 |
| Type: |  Beechcraft B200 Super King Air |
| Owner/operator: | JC Shows Ltda (Banda Calypso) |
| Registration: | PT-OSR |
| MSN: | BB-784 |
| Year of manufacture: | 1981 |
| Fatalities: | Fatalities: 2 / Occupants: 10 |
| Aircraft damage: | Destroyed, written off |
| Category: | Accident |
| Location: | 5 km N of Recife-Guararapes International Airport, PE (REC) -
 Brazil
|
| Phase: | Approach |
| Nature: | Private |
| Departure airport: | Teresina-Senador Petrônio Portela Airport, PI (THE/SBTE) |
| Recife/Guararapes-Gilberto Freyre International Airport, PE (REC/SBRF) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
During approach to landing at Guararapes International Airport runway 18, both engines quit. The pilot carried out a forced landing in a residential area. The airplane had not been refuelled at Teresina.
Contributing Factors
1 Human Factor
1.1 Medical Aspect
Nothing to report.
1.2 Psychological aspect
a) Attitude - contributed
There was a regulatory failure to comply with the operation of the aircraft by the commander, by improvising an unqualified co-pilot to make the flight. In addition, he failed to apply the amount of fuel needed to perform the flight leg.
It is possible that the attitude of overconfidence in itself also contributed, since the commander had enough experience and had total autonomy for the operation.
b) Organizational culture - contributed
There were no rules and definite rules governing the pilot's behavior. The owners gave him full autonomy for the use of the aircraft, without any monitoring of his performance or supervision of the work, in order to identify possible dysfunctions.
c) Dynamics of the team - contributed
Faced with the lack of preparation of the co-pilot, the workload was fixed on the pilot, with no integration and division of tasks between them. During the emergency, the copilot did not act, since he did not know what was going on, and kept up with what the pilot was doing.
d) Motivation - indeterminate
Given the information that the pilot was experiencing personal problems, it is possible to infer that this has developed a high motivation for the flight, thus compromising his critical capacity against a situation of risk.
e) Decision-making - contributed
There was a lack of judgment and decision making as the pilot did not consider the amount of fuel needed for the flight and did not perform the refueling of the aircraft.
1.3 Operational Aspect
a) Flight Discipline - contributed
The pilot flew with an unlicensed co-pilot and filled out the flight plan form with the license number of another pilot who did not compose the crew. In addition, it did not comply with the provisions of the regulations, regarding the correct amount of fuel to fulfill the flight.
b) Pilot trial - contributed
The pilot inadequately assessed the need for aircraft refueling for return.
c) Flight planning - undetermined
There is a possibility that the pilot may have made improper planning, or of having made a miscalculation, that may have induced him to consider aircraft refueling unnecessary.
d) Management oversight - contributed
The lack of supervision may have allowed the degradation of operations planning and execution activities.
2 Material Factor
Did not contribute.
Accident investigation:
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Sources:
Location
Revision history:
| Date/time | Contributor | Updates |
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