Incident Overview

Date: Monday 25 September 1995
Aircraft Type: Cessna 208B Grand Caravan
Owner/operator: Brasil Central
Registration Number: PT-MEQ
Location: Gruenerwinkel Mountain, Guabiruba, SC – ÿ Brazil
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 2
Component Affected: Cessna 208 AircraftCessna 208 Aircraft
Investigating Agency: CENIPACENIPA
Category: Accident
On October 26, 2023, a Cessna 208 aircraft, registration PT-MEP, carrying cargo and passengers, deviated from its planned route from Florian¢polis to Blumenau and Erexim. Due to deteriorating weather conditions, the crew diverted to Navegantes. Subsequently, the aircraft from the same company landed at Blumenau and reported worsening conditions, prompting a change to PT-MEQ. The flight was conducted below the proposed 1000ft altitude, and the aircraft flew in a valley over Brusque and Guabiruba, in a region characterized by a narrow valley on the left of the route to Blumenau. During this flight, the aircraft collided with a mountain, resulting in significant damage and a loss of altitude. Contributing factors included human factors, namely pilot fatigue and stress, psychological factors, including anxiety and complacency, and operational factors, specifically adverse weather, inadequate planning, and a failure to properly manage flight parameters. Weak cabin coordination and insufficient instruction also played a role. The company’s involvement in the investigation process, with a lack of comprehensive technical information, exacerbated the situation. Furthermore, the flight schedule, which was contrary to Brazilian aviation regulations, contributed to the incident. The crew?s limited experience and lack of sufficient navigational resources exacerbated the risks.On October 26, 2023, a Cessna 208 aircraft, registration PT-MEP, carrying cargo and passengers, deviated from its planned route from Florian¢polis to Blumenau and Erexim. Due to deteriorating weather conditions, the crew diverted to Navegantes. Subsequently, the aircraft from the same company landed at Blumenau and reported worsening conditions, prompting a change to PT-MEQ. The flight was conducted below the proposed 1000ft altitude, and the aircraft flew in a valley over Brusque and Guabiruba, in a region characterized by a narrow valley on the left of the route to Blumenau. During this flight, the aircraft collided with a mountain, resulting in significant damage and a loss of altitude. Contributing factors included human factors, namely pilot fatigue and stress, psychological factors, including anxiety and complacency, and operational factors, specifically adverse weather, inadequate planning, and a failure to properly manage flight parameters. Weak cabin coordination and insufficient instruction also played a role. The company’s involvement in the investigation process, with a lack of comprehensive technical information, exacerbated the situation. Furthermore, the flight schedule, which was contrary to Brazilian aviation regulations, contributed to the incident. The crew?s limited experience and lack of sufficient navigational resources exacerbated the risks.

Description

The crew took off from Florianopolis for Blumenau and Erexim in the Cessna 208, registration PT-MEP, carrying out a regular flight of cargo and passengers. At Blumenau there a change of aircraft was planned. Due to the weather conditions en route, the flight crew diverted to Navegantes. Another aircraft from the same company landed at Blumenau and informed via radio that the weather conditions had improved. On the basis of this information changed aircraft to PT-MEQ, and departed for Blumenau. The flight was performed below the proposed height of 1000 feet. The aircraft was seen flying between stratus layers, over Brusque and Guabiruba, in a valley on the left of the route to Blumenau. The aircraft collided with a mountain. Contributing factors a. Human Factor (1). Physiological Aspect – Undetermined The flight schedule to which the crew members were being subjected at the time they were operating in the company was contrary to Law 7.183 of 1984 and may have led them to chronic fatigue and stress conditions. (2). Psychological Aspect (a) at organisational level – undetermined There are indications that psychological variables at the organizational level, with respect to flight scale, training, standardization and procedures of the company and the flight group contributed to the accident. (b) on an individual level – contributed Throughout the operation, both crew members showed signs of anxiety, complacency, underestimation regarding the information received, motivation, change in perceptual synthesis, illusion and inattention. b. Material Factor There was no contribution from this factor. c. Operational Factor (1). Adverse Weather Conditions – Contributed The cloud base and visibility conditions made it difficult to navigate and identify the control points on the ground, as well as making it impossible to see the obstacles. (2). Disabled Panning – Contributed Insufficient planning has led to crew members failing to navigate and fly themselves. (3). Disabled Trial – Contributed The failure of the crew to judge in relation to continued flight in adverse weather conditions and below the limits set by the Rules of the Air (IMA 100-12) contributed to the accident. (4). Disabled Instruction – Undefined There is evidence of the company’s involvement in the investigation process, which did not give the crew the full technical conditions necessary for the flight to take place. (5). Weak Cabin Coordination – Contributed The failures committed on this flight indicate that at least one crew member failed to use the available navigation resources and the other failed to advise. (6). Influence of the Environment – Contributed There was an influence of the visibility and ceiling conditions, as well as the physical environment, in relation to the similarity between the valleys of the Itaja¡ River and Itaja¡ Mirim. There is also evidence that conditions in the administrative-operational environment of the company and the group of pilots contributed to the difficulties the pilots faced. (7). Disabled Supervision – Contributed The errors found imply failures of supervision in the flight schedule sector, with regard to compliance with the law, training and operations sector. (8). Others – Contributed The crew had little experience as pilots in the company and on the route flown.

Source of Information

https://omunicipio.com.br/queda-de-aviao-em-guabiruba-completa-25-anos-veja-relatos-de-quem-testemunhou-o-acidente/https://omunicipio.com.br/queda-de-aviao-em-guabiruba-completa-25-anos-veja-relatos-de-quem-testemunhou-o-acidente/

Primary Cause

Human Factors (1) ? Pilot fatigue and stress, coupled with psychological factors of anxiety, complacency, and underestimation of weather conditions.Human Factors (1) ? Pilot fatigue and stress, coupled with psychological factors of anxiety, complacency, and underestimation of weather conditions.

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