Incident Overview

Date: Sunday 23 November 2008
Aircraft Type: Beechcraft B200 Super King Air
Owner/operator: JC Shows Ltda (Banda Calypso)
Registration Number: PT-OSR
Location: 5 km N of Recife-Guararapes International Airport, PE (REC) – ÿ Brazil
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 10
Component Affected: Aircraft Engine SystemAircraft Engine System
Investigating Agency: CENIPACENIPA
Category: Accident
During approach to landing at Guararpes International Airport runway 18, both engines abruptly quit. The pilot initiated a forced landing, carrying out a flight without refueling. Contributing factors included a regulatory failure to comply with aircraft operation, a lack of oversight and supervision, and a pilot exhibiting potential psychological issues ? including a regulatory failure to comply with operational requirements and an attitude of overconfidence. Organizational culture, characterized by a lack of established rules and autonomy, exacerbated the situation. The pilot’s lack of preparation and decision-making regarding fuel requirements contributed to the incident. The co-pilot’s inadequate actions and lack of situational awareness resulted in the flight being aborted.During approach to landing at Guararpes International Airport runway 18, both engines abruptly quit. The pilot initiated a forced landing, carrying out a flight without refueling. Contributing factors included a regulatory failure to comply with aircraft operation, a lack of oversight and supervision, and a pilot exhibiting potential psychological issues ? including a regulatory failure to comply with operational requirements and an attitude of overconfidence. Organizational culture, characterized by a lack of established rules and autonomy, exacerbated the situation. The pilot’s lack of preparation and decision-making regarding fuel requirements contributed to the incident. The co-pilot’s inadequate actions and lack of situational awareness resulted in the flight being aborted.

Description

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. 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.

Primary Cause

Regulatory failure to comply with aircraft operation, combined with a lack of oversight and a pilot’s attitude of overconfidence and insufficient preparation.Regulatory failure to comply with aircraft operation, combined with a lack of oversight and a pilot’s attitude of overconfidence and insufficient preparation.

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