Date:	Monday 11 November 1991
Time:	21:43
Type:	Embraer EMB-110P1 Bandeirante
Owner/operator:	Nordeste Linhas Aéreas
Registration:	PT-SCU
MSN:	110314
Year of manufacture:	1980
Total airframe hrs:	3973 hours
Engine model:	Pratt & Whitney Canada PT6A-34
Fatalities:	Fatalities: 15 / Occupants: 15
Other fatalities:	2
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	0,5 km NE of Recife-Guararapes International Airport, PE (REC) -   Brazil
Phase:	Initial climb
Nature:	Passenger - Scheduled
Departure airport:	Recife-Guararapes International Airport, PE (REC/SBRF)
Destination airport:	Salvador-Dois de Julho International Airport, BA (SSA/SBSV)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
The Bandeirante was piloted by a DAC check pilot and a co-pilot from Nordeste. During takeoff the right engine suffered a failure. A fire erupted immediately. Takeoff was continued and the airplane rotated after 900 m instead of the usual 570 m. The Bandeirante barely climbed and then another bang was heard. Flaming debris fell from the right hand engine, setting fire to an area within the airport perimeter fence. The airplane climbed to a height of 30 m and yawed to the right. The flight crew applied the wrong technique to counter the yaw. Some thirty seconds after takeoff the aircraft collided with two residences and crashed onto a public square.
It was determined that the temperature indicator for the right hand engine was faulty, displaying a lower than actual temperature. The engine operated for some time at high temperatures because of the faulty system. It was also found that, after completion, some maintenance and inspection tasks were just signed by the maintenance engineer. Signatures from the maintenance inspector were missing.

CONCLUSION:

Human Factor - Psychological Aspect - Contributed
At the individual level, the delay in the decision making of the pilots as to the appropriate procedures for that emergency situation. At the organizational level, the lack of adequate training for emergency situations and the absence of activities to prevent aviation accidents in the company.

Material Factor
(1) Project Deficiency - Contributed
The "T5 Bus Bar Assembly" set, specifically the Bus Bar's insulation and fastening system, proved to be deficient. The detachment of their insulation gloves had the double consequence of causing erroneous TIT indication and clogging of the vanes' cooling holes, aggravated by the maintenance aspect.
(2) Manufacturing Deficiency - Contributed
There was a deficiency in the process of casting the compressor turbine stator assembly (CT Vane Ring), generating fins with wall thicknesses different from those predicted in the design.

Operational Factor
(1) Poor Application of Commands - Undetermined
This factor was not fully characterized due to the inexistence of flight data recorders that could confirm their participation. The pilot could have compensated the rudder to the wrong side after the engine failure or the rudder compensator could already be in the wrong compensation to counteract the yaw tendency of the aircraft.
(2) Poor Maintenance - Contributed
Due to the notoriety of the facts and evidence raised in the investigation, there was a failure by the company during the HSI (Hot Section Inspection), when the limits of CT Vane Ring cracks were not observed.
(3) Poor Instruction - Contributed
The company did not meet the minimum requirements for crew members to operate the aircraft properly in emergency situations, as required by RBHA 135.
(4) Poor Supervision - Present and Indeterminate Contribution.
The company did not comply with aviation standards in order to supervise the execution of the maintenance services performed.
(5) Poor Judgment - Contributed
The takeoff could and should have been aborted by the pilot in command.
(6) Influence of the Environment - Undetermined
The take-off was carried out at night time and, considering the particularities of this situation, it was possible that the environment contributed negatively to the pilot's judgment, by choosing to continue the takeoff.

CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos

Date/time	Contributor	Updates
15-Mar-2024 20:39	ASN	Updated [Accident report]