Unfallbericht:
The aircraft operated on a delivery flight from the Embraer factory at São José dos Campos Airport. Atlantic Southeast Airlines was taking delivery of the aircraft and the first ferry legs would take the aircraft to Brasília and Manaus.
The flight was cleared by the São José Tower controller to follow the 010 degrees radial to the SJC VOR, and cross the VOR at 5000 feet.
Some time after takeoff São José Tower instructed the flight to climb to FL280 out of 5000 feet and intercept the 352 radial of the SJC VOR. The flight crew failed to follow the instructions. This was not noticed when the crew contacted Brasília ACC.
The airplane continued at 5000 feet until it struck a cloud covered mountain in the Mantiqueira Mountains at an elevation of 5000 feet, 700 feet below the peak.
PROBABLE CAUSE (translated from Portuguese):
- The pilots did not plan the flight properly, though there was an AIS room with the necessary sources of consultation. Maintaining altitude of 5000 feet for too long a time, subject to the minimum safe altitudes in the are area in the available publications, and the discrepancies found in the flight plan confirm this thesis.
- The pilot did not properly collated the guidelines issued by the tower and remained incompatible altitude with instructions issued by the control.
- There are strong indications that the flight proceeded under instrument flight conditions.
- There was no proper coordination between the ACC BS and TWR SJ regarding the transference and control of the air traffic nor did TWR SJ requested receipt of the messages.
» ICAO Adrep Summary 5/94 (#45)
» SIPAER final report
| Status: | Accident investigation report completed and information captured |
| Datum: | Freitag 19 September 1986 |
| Zeit: | 14:58 |
| Flugzeugtyp: |  Embraer EMB-120RT Brasilia |
| Operated by: | Atlantic Southeast Airlines - ASA |
| On behalf of: | Delta Connection |
| Kennzeichen: | N219AS |
| Werknummer: | 120019 |
| Baujahr: | 1986 |
| Betriebsstunden: | 12 |
| Triebwerk: | 2 Pratt & Whitney Canada PW115 |
| Besatzung: | Todesopfer: 3 / Insassen: 3 |
| Fluggäste: | Todesopfer: 2 / Insassen: 2 |
| Gesamt: | Todesopfer: 5 / Insassen: 5 |
| Sachschaden: | Zerstört |
| Konsequenzen: | Written off (damaged beyond repair) |
| Unfallort: | nahe Mantiqueira, SP ( Brasilien)
|
| Flugphase: | Während des Fluges (ENR) |
| Betriebsart: | Leerflug |
| Flug von: | São José dos Campos Airport, SP (SJK/SBSJ), Brasilien |
| Brasília International Airport, DF (BSB/SBBR), Brasilien |
The aircraft operated on a delivery flight from the Embraer factory at São José dos Campos Airport. Atlantic Southeast Airlines was taking delivery of the aircraft and the first ferry legs would take the aircraft to Brasília and Manaus.
The flight was cleared by the São José Tower controller to follow the 010 degrees radial to the SJC VOR, and cross the VOR at 5000 feet.
Some time after takeoff São José Tower instructed the flight to climb to FL280 out of 5000 feet and intercept the 352 radial of the SJC VOR. The flight crew failed to follow the instructions. This was not noticed when the crew contacted Brasília ACC.
The airplane continued at 5000 feet until it struck a cloud covered mountain in the Mantiqueira Mountains at an elevation of 5000 feet, 700 feet below the peak.
Probable Cause:
PROBABLE CAUSE (translated from Portuguese):
- The pilots did not plan the flight properly, though there was an AIS room with the necessary sources of consultation. Maintaining altitude of 5000 feet for too long a time, subject to the minimum safe altitudes in the are area in the available publications, and the discrepancies found in the flight plan confirm this thesis.
- The pilot did not properly collated the guidelines issued by the tower and remained incompatible altitude with instructions issued by the control.
- There are strong indications that the flight proceeded under instrument flight conditions.
- There was no proper coordination between the ACC BS and TWR SJ regarding the transference and control of the air traffic nor did TWR SJ requested receipt of the messages.
Informationsquelle:
» Flight International 4 October 1986» ICAO Adrep Summary 5/94 (#45)
» SIPAER final report
Sicherheitsempfehlungen
NTSB issued 6 Safety Recommendations
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Fotos
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 São José dos Campos Airport, SP to Brasília International Airport, DF as the crow flies is 844 km (527 miles).
Accident location: Global; accuracy within tens or hundreds of kilometers.
Distance from São José dos Campos Airport, SP to Brasília International Airport, DF as the crow flies is 844 km (527 miles).
Accident location: Global; accuracy within tens or hundreds of 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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