Let L-410UVP-E20 – PT-FSE

Incident Overview

Date: Friday 31 March 2006

Aircraft Type: Let L-410UVP-E20

Owner/operator: TEAM Transportes Areos

Registration Number: PT-FSE

Location: 6 km SE of Rio Bonito, RJ – ÿ Brazil

Phase of Flight: En route

Status: Destroyed, written off

Casualties: Fatalities: 19 / Occupants: 19

Component Affected: AircraftAircraft

Investigating Agency: CENIPACENIPA

Category: Accident

On July 17, 2023, a fatal accident occurred when a Flight 6865 aircraft, en route to Rio de Janeiro, experienced a collision with trees near Pico da Pedra Bonita. The aircraft was initially planned to continue under visual flight rules (VFR) at a lower altitude of 2000 feet, but the crew initiated a cancellation of their IFR plan and requested a descent to avoid adverse weather conditions. After takeoff, the crew determined to descend to 2000 feet, which resulted in a catastrophic collision with the terrain. Contributing factors included inadequate crew decision-making, specifically concerning low-altitude flight and insufficient risk assessment, a complacent organizational culture prioritizing low-altitude operations, inadequate operational procedures, and a failure to adequately address weather conditions. The pilot’s decision to cancel the IFR plan, coupled with the lack of a comprehensive meteorological analysis, contributed to the accident. Furthermore, the crew’s decision to fly at a lower altitude than safe limits, compounded by the absence of proper visual conditions, directly led to the collision. The company’s oversight in failing to implement stringent safety procedures and provide adequate supervisory oversight exacerbated the situation.On July 17, 2023, a fatal accident occurred when a Flight 6865 aircraft, en route to Rio de Janeiro, experienced a collision with trees near Pico da Pedra Bonita. The aircraft was initially planned to continue under visual flight rules (VFR) at a lower altitude of 2000 feet, but the crew initiated a cancellation of their IFR plan and requested a descent to avoid adverse weather conditions. After takeoff, the crew determined to descend to 2000 feet, which resulted in a catastrophic collision with the terrain. Contributing factors included inadequate crew decision-making, specifically concerning low-altitude flight and insufficient risk assessment, a complacent organizational culture prioritizing low-altitude operations, inadequate operational procedures, and a failure to adequately address weather conditions. The pilot’s decision to cancel the IFR plan, coupled with the lack of a comprehensive meteorological analysis, contributed to the accident. Furthermore, the crew’s decision to fly at a lower altitude than safe limits, compounded by the absence of proper visual conditions, directly led to the collision. The company’s oversight in failing to implement stringent safety procedures and provide adequate supervisory oversight exacerbated the situation.

Description

TEAM Flight 6865 departed Maca (MEA) at 17:19 on an IFR flight plan to Rio de Janeiro (SDU). The airplane was expected to arrive at 18:02. After takeoff the crew requested cancellation of their IFR flight plan ant to continue under visual flight rules at FL45. This was approved. Upon request, the flight was cleared to descend to 2000 feet to avoid an area of poor weather. About 17:39 a left turn was initiated towards the coast line for the same reason. The airplane struck trees near the top of Pico da Pedra Bonita at an elevation of 1920 feet. CONTRIBUTING FACTORS (translated from Portuguese) 1. Human factors Psychological – Contributed It was found that the decision of the crew to cancel the IFR plan to continue VFR at low altitude and when visibility is not favorable, has been inadequate, with compliance of the pilots with such a decision. It is possible that the knowledge of the region obtained by the instructor captain caused over-confidence, influencing the decision. The organizational culture of the company proved to be complacent by not inhibiting the adoption of procedures incompatible with flight safety, such as the low altitude flights made by the instructor captain. Operational Aspect a. Judgement – Contributed There was inadequate assessment of the situation by the crew, causing them to fly at a lower altitude than the safe limits under visual conditions unsuitable for visual flight, resulting in the collision of the aircraft with high ground. b. Coordination Cabin – Contributed The use of human resources for the operation of the aircraft was unsuitable because of failure to comply with operational standards, leading the crew to perform a passenger flight to the lower altitude limits of safety, under inadequate visual conditions. c. Planning – Contributed The preparation for the flight proved inadequate because the crew did not have a meteorological analysis of the appropriate level of flight performed, considering that the conditions for the region were overshadowing the Serra do Mar and surrounding areas of low clouds and / or mist, especially on the slopes of the mountain. d. Adverse weather conditions – Contributors The weather conditions prevailing in the region made visual flight impossible, resulting in the concealment of the elevation at which the aircraft crashed. e. Flight indiscipline – Contributed The pilots intentionally not complying with rules of air traffic and civil aviation rules, without grounds, performing flight at low altitude, under conditions of visibility below the limits established for VFR flight, colliding with high ground. f Supervision – Contributed The company has not taken appropriate supervisory measures, enabling the existence of a culture of undeveloped flight safety, which prevented advance identification of actions taken by the crew and injured misconception exists in the CRM business, which represented a potential risk to their operations, as well as by the failure of some educational measures provided for in its PPAA (Plan for the Prevention of Aeronautical Accidents). 2 Material Factor Not contributed. Not contributed

Primary Cause

Inadequate crew decision-making and risk assessment, specifically concerning low-altitude flight and insufficient risk assessment, combined with a complacent organizational culture prioritizing low-altitude operations.Inadequate crew decision-making and risk assessment, specifically concerning low-altitude flight and insufficient risk assessment, combined with a complacent organizational culture prioritizing low-altitude operations.

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