ASN Wikibase Occurrence # 188975
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| Date: | Sunday 31 July 2016 |
| Time: | 21:00 LT |
| Type: |  Embraer EMB-820C Navajo |
| Owner/operator: | Fenatracoop |
| Registration: | PT-EFQ |
| MSN: | 820-030 |
| Year of manufacture: | 1970 |
| Fatalities: | Fatalities: 8 / Occupants: 8 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Marechal Hermes da Fonseca Street, Londrina, Parana -
 Brazil
|
| Phase: | Landing |
| Nature: | Private |
| Departure airport: | Cuiabá-Marechal Rondon International Airport, Mato Grosso (CGB/SBCY) |
| Londrina–Gov. José Richa Airport, Londrina, Brazil (LDB/SBLO) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The twin engine aircraft was performing a flight from Cuiabá to Londrina with a crew of two and six passengers (three adults and three children). On approach to runway 13 in Londrina, the aircraft stalled and crashed onto a hangar located in the Marechal Hermes da Fonseca Street, about 5 km from runway 13 threshold.
As six tanker trucks were parked in the hangar, severe explosions occurred and none of the eight occupants survived the crash. No other people on the ground were injured. An engine failure is suspected according to locals.
Contributing factors.
- Communication – undetermined.
It is possible that difficulties for the dialogue between pilots on matters related to the operation of the aircraft have favored a prejudicial scenario to the expression of assertiveness in the communication in the cabin, interfering in the effective management of the presented abnormal condition.
- Team dynamics – undetermined.
It is possible that a more passive posture of the copilot combined with the commander's decisions and actions from the presentation of the abnormal condition in flight interfered with the quality of the team's integration and in the efficiency of the cabin dynamics during the occurrence, bringing losses to the emergency management presented.
- Emotional state – undetermined.
It is not possible to discard the hypothesis that a more anxious emotional state of the pilots contributed to an inaccurate evaluation of the operational context experienced, favoring ineffective judgments, decisions and actions to manage the abnormal condition presented.
- Aircraft maintenance – a contributor.
On the right engine, it was found that the fuel tube fixing nut that left the distributor for No. 3 cylinder was loose, favoring the fuel leakage, as well as the bypass valve clamp of the turbocharger that was bad adjusted, providing leakage of gases from the exhaust that would be directed to the compressor and, later to the engine, to equalize its power.
On the left engine, impurity composed of an agglomerate of soil and fuel were found on the side of the nozzles n° 2, 4 and 6, which migrated to the inside of these nozzles, causing them to become clogged.
It was not possible to determine the origin of this material, but there is a possibility that it may have been deposited during the long period the aircraft spent in the maintenance shop, undergoing general overhaul and the revitalization of its interior (13DEC2012 until 29APR2016).
- Insufficient pilot’s experience – undetermined.
The pilots had little experience with the GARMIN GTN 650 navigation system. The lack of familiarity with this equipment may have favored the misidentification of the approach fixes for Londrina. This way, it is possible that they have calculated their descent to the final approach fix (waypoint LO013), believing that it was the position relative to threshold 13 (waypoint RWY13).
- Decision-making process – undetermined.
The decision to take off from Cuiabá to Londrina without the identification of the reason for the warning light to be ON in the alarm panel and the possible late declaration of the emergency condition showed little adequate decisions that may have increased the level of criticality of the occurrence.
- Support systems – undetermined.
The similarity of the waypoints names in the RNAV procedure, associated with the lack of familiarity of the pilots with the new navigation system installed in the aircraft, may have confused the pilots as to their real position in relation to the runway.
Accident investigation:
 |
|
Sources:
1. http://g1.globo.com/pr/norte-noroeste/noticia/2016/07/aviao-cai-e-deixa-pelo-menos-cinco-mortos-em-londrina-no-norte-do-pr.html
2. http://www.midianews.com.br/cotidiano/aviao-que-decolou-de-varzea-grande-cai-em-londrina/270415
3. http://www.folhamax.com/policia/aviao-sai-de-cuiaba-e-cai-em-londrina-oito-morrem-na-hora/94150
4. http://fenatracoop.com.br/site/nota-de-falecimento-2/
5. http://web.archive.org/web/20170501111448/http://www.baaa-acro.com:80/2016/archives/crash-of-a-embraer-emb-820c-navajo-in-londrina-8-killed/
6. http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/en/PT-EFQ_31_07_2016_AC_ing.pdf
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 01-Aug-2016 06:08 | cleberjc | Added |
| 01-Aug-2016 06:10 | harro | Updated [Aircraft type, Total fatalities, Total occupants, Location, Source, Narrative] |
| 01-Aug-2016 06:12 | harro | Updated [Departure airport, Narrative] |
| 01-Aug-2016 07:18 | Aerossurance | Updated [Narrative] |
| 01-Aug-2016 07:36 | Dmitriy | Updated [Aircraft type, Registration, Cn, Operator, Source] |
| 01-Aug-2016 14:57 | cleberjc | Updated [Departure airport, Destination airport, Embed code, Narrative] |
| 01-Aug-2016 17:16 | Dmitriy | Updated [Operator, Source, Narrative] |
| 05-Aug-2016 17:53 | Anon. | Updated [Phase, Narrative] |
| 23-Oct-2017 19:12 | Dr. John Smith | Updated [Cn, Location, Destination airport, Source, Narrative] |
| 26-May-2020 14:53 | KagurazakaHanayo | Updated [Source, Narrative] |
| 26-May-2020 14:55 | harro | Updated [Narrative, Accident report, ] |
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