Incident Overview

Date: Friday 19 September 1986
Aircraft Type: Embraer EMB-120RT Brasilia
Owner/operator: Delta Connection, opb Atlantic Southeast Airlines – ASA
Registration Number: N219AS
Location: near Mantiqueira, SP – ÿ Brazil
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 5 / Occupants: 5
Component Affected: Embraer aircraftEmbraer aircraft
Category: Accident
An Embraer aircraft, en route from S?o Jos‚ dos Campos Airport to Bras¡lia and Manaus via Atlantic Southeast Airlines, experienced a near-miss incident due to pilot misinterpretation of tower instructions. The aircraft initially climbed to FL280, then deviated to intercept the SJC VOR radial, and subsequently struck a cloud-covered mountain at a low altitude. The incident was not immediately noticed by the flight crew, leading to continued flight at 5000 feet.An Embraer aircraft, en route from S?o Jos‚ dos Campos Airport to Bras¡lia and Manaus via Atlantic Southeast Airlines, experienced a near-miss incident due to pilot misinterpretation of tower instructions. The aircraft initially climbed to FL280, then deviated to intercept the SJC VOR radial, and subsequently struck a cloud-covered mountain at a low altitude. The incident was not immediately noticed by the flight crew, leading to continued flight at 5000 feet.

Description

The aircraft operated on a delivery flight from the Embraer factory at S?o Jos‚ dos Campos Airport. Atlantic Southeast Airlines was taking delivery of the aircraft and the first ferry legs would take the aircraft to Bras¡lia and Manaus. The flight was cleared by the S?o Jos‚ Tower controller to follow the 010 degrees radial to the SJC VOR, and cross the VOR at 5000 feet. Some time after takeoff S?o Jos‚ 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 Bras¡lia 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.

Primary Cause

Pilot misinterpretation of tower instructions regarding altitude and flight path, coupled with inconsistent flight plan adherence and lack of coordination between the S?o Jos‚ Tower and Bras¡lia Air Traffic Control (TWR) stations.Pilot misinterpretation of tower instructions regarding altitude and flight path, coupled with inconsistent flight plan adherence and lack of coordination between the S?o Jos‚ Tower and Bras¡lia Air Traffic Control (TWR) stations.

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