Narrative:
The Bandeirante departed São Paulo's Guarulhos Airport at 03:58 hours local time on a cargo flight to Uberaba, Brazil.
The aircraft carried 1524 kg of cargo, bringing the takeoff weight to 6348 kg, whereas the maximum takeoff weight was 5600 kg.
The en route part of the flight was uneventful and at 04:58 hours the flight crew prepared for an NDB approach to runway 17. However, weather had worsened with visibility conditions below minima. Uberaba reported a ceiling of 100 feet and visibility of 800 m, which later decreased to 500 m.
At 05:03 the pilots adjusted their altimeters and identified a difference between them of 150 feet. The captain reported that he would use the co-pilot's altimeter.
From 05:10 until 05:15 the pilots performed the approach procedure with ADF and GPS references, reaching 3300 feet on the final approach leg, with flaps at 50% and undercarriage down and locked. Airport elevation is 2655 feet and MDA was 3000 feet.
The flight descended below MDA as the captain was looking for the runway in a hole in the clouds. As weight of unsecured cargo had shifted, the aircraft stalled and crashed onto a house in the Rua Uirapuru, killing one person inside. The Bandeirante was approaching runway 17.
Contributing Factors
a. Human Factors
Psychological - Contributed
The organizational culture of the company allows the practice of behaviors that are not assertive, complacent and lack of respect for established norms and procedures.
The co-pilot's poor assertiveness and complacency, coupled with the commander's overconfidence, drove the crew down below the MDA, colliding with the obstacles.
b. Material Factor
Did not contribute
c. Operational Factor
(1) Adverse Weather Conditions - Contributed
The weather conditions at the time of the accident did not allow pilots to spot the existing obstacles.
(2) Judgment - Contributed
There was an inadequate evaluation of the situation in the implementation of the descent procedure, leading the crew to proceed below the MDA in the instrument approach, without having obtained visual references with the ground.
(3) Planning - Contributed
The preparation for the instrument approach was not covered by a planning that approached its correct execution, with the crew planning to descend below the MDA, even though they knew that the ceiling and the visibility were lower than required for the descent procedure.
(4) Supervision - Contributed
The supervision practiced by the operator in the execution of the aerial activity was not being comprehensive, allowing the development of behaviors of complacency and disregard for established norms and procedures, as well as lack of CRM training on the part of its crew and activities in the PPAA.
The supervisory practices developed by the company allowed the loading of its aircraft with a weight above the maximum allowed, reducing the margin of safety, causing the aircraft to enter a stall with higher speed, during the approach of SBUR.
It is possible that the lack of supervision would lead to the transport of cargo without a retention net, allowing the change of the CG due to the movement of the load inside the aircraft, contributing to the stall entry when the attack.
(5) Application of the Commands - Contributed
The pilot acted on the controls of the aircraft to allow it to stall during the approach, losing its control and colliding with the obstacles.
(6) Cabin Coordination - Contributed
Coordination among the pilots to perform the descent procedure proved to be inadequate since there was no effective interaction between them.
(7) Flight Discipline - Contributed
The aircraft descended below the MDA with a weight higher than the manufacturer allowed, entering stall during the approach, colliding with obstacles.
(8) Oblivion - Undetermined
Assuming that the co-pilot's altimeter was 150 feet higher than that of the commander, it is admitted that he might have forgotten to use the altimetry references of the co-pilot's instrument, using those of his, going lower than he intended, coming to collide with the obstacles.
(9) Support Staff - Undetermined
The possibility that the support personnel has not placed a load net on the aircraft, allowing the movement of this inside the aircraft, contributing to the stall entry when the attitude change in the approach, is allowed.
Loss of control
METAR SBUR 110500Z 33004KT CAVOK 19/19 Q1010
06:00 UTC / 04:00 local time:
METAR SBUR 110600Z 07002KT CAVOK 20/20 Q1010
06:43 UTC / 04:43 local time:
SPECI SBUR 110643Z 16003KT 8000 0800S PRFG BKN001 19/19 Q1010
07:00 UTC / 05:00 local time:
METAR SBUR 110700Z 18002KT 0800 FG BKN001 19/19 Q1010
07:37 UTC / 05:37 local time:
SPECI SBUR 110737Z 26001KT 0200 FG BKN001 19/19 Q1010
| Status: | Accident investigation report completed and information captured |
| Date: | Saturday 11 December 2004 |
| Time: | 05:16 |
| Type: |  Embraer EMB-110 Bandeirante |
| Operator: | NHR Táxi-Aéreo |
| Registration: | PT-WAK |
| MSN: | 110071 |
| First flight: | 1975 |
| Total airframe hrs: | 11689 |
| Engines: | 2 Pratt & Whitney Canada PT6A-27 |
| Crew: | Fatalities: 2 / Occupants: 2 |
| Passengers: | Fatalities: 0 / Occupants: 0 |
| Total: | Fatalities: 2 / Occupants: 2 |
| Ground casualties: | Fatalities: 1 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | 0,8 km (0.5 mls) from Uberaba Airport, MG (UBA) ( Brazil)
|
| Crash site elevation: | 809 m (2654 feet) amsl |
| Phase: | Approach (APR) |
| Nature: | Cargo |
| Departure airport: | São Paulo-Guarulhos International Airport, SP (GRU/SBGR), Brazil |
| Uberaba Airport, MG (UBA/SBUR), Brazil |
The Bandeirante departed São Paulo's Guarulhos Airport at 03:58 hours local time on a cargo flight to Uberaba, Brazil.
The aircraft carried 1524 kg of cargo, bringing the takeoff weight to 6348 kg, whereas the maximum takeoff weight was 5600 kg.
The en route part of the flight was uneventful and at 04:58 hours the flight crew prepared for an NDB approach to runway 17. However, weather had worsened with visibility conditions below minima. Uberaba reported a ceiling of 100 feet and visibility of 800 m, which later decreased to 500 m.
At 05:03 the pilots adjusted their altimeters and identified a difference between them of 150 feet. The captain reported that he would use the co-pilot's altimeter.
From 05:10 until 05:15 the pilots performed the approach procedure with ADF and GPS references, reaching 3300 feet on the final approach leg, with flaps at 50% and undercarriage down and locked. Airport elevation is 2655 feet and MDA was 3000 feet.
The flight descended below MDA as the captain was looking for the runway in a hole in the clouds. As weight of unsecured cargo had shifted, the aircraft stalled and crashed onto a house in the Rua Uirapuru, killing one person inside. The Bandeirante was approaching runway 17.
Probable Cause:
Contributing Factors
a. Human Factors
Psychological - Contributed
The organizational culture of the company allows the practice of behaviors that are not assertive, complacent and lack of respect for established norms and procedures.
The co-pilot's poor assertiveness and complacency, coupled with the commander's overconfidence, drove the crew down below the MDA, colliding with the obstacles.
b. Material Factor
Did not contribute
c. Operational Factor
(1) Adverse Weather Conditions - Contributed
The weather conditions at the time of the accident did not allow pilots to spot the existing obstacles.
(2) Judgment - Contributed
There was an inadequate evaluation of the situation in the implementation of the descent procedure, leading the crew to proceed below the MDA in the instrument approach, without having obtained visual references with the ground.
(3) Planning - Contributed
The preparation for the instrument approach was not covered by a planning that approached its correct execution, with the crew planning to descend below the MDA, even though they knew that the ceiling and the visibility were lower than required for the descent procedure.
(4) Supervision - Contributed
The supervision practiced by the operator in the execution of the aerial activity was not being comprehensive, allowing the development of behaviors of complacency and disregard for established norms and procedures, as well as lack of CRM training on the part of its crew and activities in the PPAA.
The supervisory practices developed by the company allowed the loading of its aircraft with a weight above the maximum allowed, reducing the margin of safety, causing the aircraft to enter a stall with higher speed, during the approach of SBUR.
It is possible that the lack of supervision would lead to the transport of cargo without a retention net, allowing the change of the CG due to the movement of the load inside the aircraft, contributing to the stall entry when the attack.
(5) Application of the Commands - Contributed
The pilot acted on the controls of the aircraft to allow it to stall during the approach, losing its control and colliding with the obstacles.
(6) Cabin Coordination - Contributed
Coordination among the pilots to perform the descent procedure proved to be inadequate since there was no effective interaction between them.
(7) Flight Discipline - Contributed
The aircraft descended below the MDA with a weight higher than the manufacturer allowed, entering stall during the approach, colliding with obstacles.
(8) Oblivion - Undetermined
Assuming that the co-pilot's altimeter was 150 feet higher than that of the commander, it is admitted that he might have forgotten to use the altimetry references of the co-pilot's instrument, using those of his, going lower than he intended, coming to collide with the obstacles.
(9) Support Staff - Undetermined
The possibility that the support personnel has not placed a load net on the aircraft, allowing the movement of this inside the aircraft, contributing to the stall entry when the attitude change in the approach, is allowed.
Accident investigation:
 |
|
Classification:
Centre of Gravity outside limits Loss of control
METAR Weather report:
05:00 UTC / 03:00 local time:METAR SBUR 110500Z 33004KT CAVOK 19/19 Q1010
06:00 UTC / 04:00 local time:
METAR SBUR 110600Z 07002KT CAVOK 20/20 Q1010
06:43 UTC / 04:43 local time:
SPECI SBUR 110643Z 16003KT 8000 0800S PRFG BKN001 19/19 Q1010
07:00 UTC / 05:00 local time:
METAR SBUR 110700Z 18002KT 0800 FG BKN001 19/19 Q1010
07:37 UTC / 05:37 local time:
SPECI SBUR 110737Z 26001KT 0200 FG BKN001 19/19 Q1010
Photos
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 Paulo-Guarulhos International Airport, SP to Uberaba Airport, MG as the crow flies is 435 km (272 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from São Paulo-Guarulhos International Airport, SP to Uberaba Airport, MG as the crow flies is 435 km (272 miles).
Accident location: Approximate; accuracy within a few 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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