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Status:Schlussbericht
Datum:Sonntag 23 November 2008
Zeit:11:15
Flugzeugtyp:Silhouette image of generic BE20 model; specific model in this crash may look slightly different
Beechcraft B200 Super King Air
Fluggesellschaft:JC Shows Ltda (Banda Calypso)
Kennzeichen: PT-OSR
Werknummer: BB-784
Baujahr: 1981
Besatzung:Todesopfer: 1 / Insassen: 2
Fluggäste:Todesopfer: 1 / Insassen: 8
Gesamt:Todesopfer: 2 / Insassen: 10
Sachschaden: Zerstört
Konsequenzen: Written off (damaged beyond repair)
Unfallort:5 km (3.1 Meilen) N of Recife-Guararapes International Airport, PE (REC) (   Brasilien)
Flugphase: Annäherung (APR)
Betriebsart:Privat
Flug von:Teresina-Senador Petrônio Portela Airport, PI (THE/SBTE), Brasilien
Flug nach:Recife-Guararapes International Airport, PE (REC/SBRF), Brasilien
Unfallbericht:
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.

Probable Cause:

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:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 1 year and 7 months
Accident number: RF A-038/CENIPA/2010
Download report: Final report
Language: Portuguese


Sicherheitsempfehlungen

CENIPA issued 10 Safety Recommendations

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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 Teresina-Senador Petrônio Portela Airport, PI to Recife-Guararapes International Airport, PE as the crow flies is 933 km (583 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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Beech King Air

  • 3550+ built
  • 154th loss
  • 93rd Fataler Unfall
  • 53rd worst accident (Zu diesem Zeitpunkt)
  • 81st worst accident (Momentan)
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