Incident Overview

Date: Monday 22 June 1992
Aircraft Type: Boeing 737-2A1C
Owner/operator: VASP – Via‡?o A‚rea S?o Paulo
Registration Number: PP-SND
Location: 15 km W of Cruzeiro do Sul-Campo Internacional Airport, AC (CZS) – ÿ Brazil
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 3 / Occupants: 3
Component Affected: Aircraft Flight Control SystemAircraft Flight Control System
Investigating Agency: CENIPACENIPA
Category: Accident
During the descent to Cruzeiro do Sul, an aircraft experienced a loss of control due to a combination of factors related to human error, operational deficiencies, and inadequate oversight. The aircraft crashed in the jungle while performing a Delta 1 arrival to runway 10. The primary contributing factors were a combination of human factors ? specifically, the psychological impact of the high-level anxiety during the landing and diversion of attention ? and operational deficiencies, including deficient instruction, inadequate maintenance, and insufficient cockpit coordination. The dark night conditions exacerbated the situation, contributing to a ‘black hole’ effect that made it difficult to perceive the aircraft’s position. Furthermore, inadequate oversight at all levels, from cockpit supervision to company-level management, played a significant role in the incident. Specifically, the failure to adhere to established descent procedures, the lack of radio altimeter use, and the inadequate altitude alert system all contributed to the loss of control.During the descent to Cruzeiro do Sul, an aircraft experienced a loss of control due to a combination of factors related to human error, operational deficiencies, and inadequate oversight. The aircraft crashed in the jungle while performing a Delta 1 arrival to runway 10. The primary contributing factors were a combination of human factors ? specifically, the psychological impact of the high-level anxiety during the landing and diversion of attention ? and operational deficiencies, including deficient instruction, inadequate maintenance, and insufficient cockpit coordination. The dark night conditions exacerbated the situation, contributing to a ‘black hole’ effect that made it difficult to perceive the aircraft’s position. Furthermore, inadequate oversight at all levels, from cockpit supervision to company-level management, played a significant role in the incident. Specifically, the failure to adhere to established descent procedures, the lack of radio altimeter use, and the inadequate altitude alert system all contributed to the loss of control.

Description

During the descent to Cruzeiro do Sul, the crew’s attention was distracted by the cargo compartment fire warning system, which began to activate intermittently. The aircraft crashed in the jungle while performing a Delta 1 arrival to runway 10. Contributing factors a. Human Factor (1) . Physiological Aspect – There was no evidence of this aspect contributing to the occurrence of the accident. (2). Psychological Aspect – Contributed – The psychological aspect contributed through the generation of a high level of anxiety to perform the landing and in the diversion of the focus of attention during the approach manoeuvres to land. – The psychological aspect was influenced by the activation of the smoke alarm which generated an increase in the workload on board. b. Material Factor – There were no indications that this factor contributed to the accident. c. Operational Factor (1). Deficient Instruction – Although the instruction was carried out in accordance with what the standards recommend, the failures that contributed to the accident are characteristic of lack of experience in facing abnormalities simultaneously with the maintenance of flight control. Such failures could be avoided with more adequate simulator instructions and training involving the cockpit management aspects. (2). Poor Maintenance – Undetermined . – It was not possible to determine the cause of the activation of the “Aft Cargo Smoke” alarm and whether the maintenance services contributed to this occurrence. (3). Deficient Cockpit Coordination – Inadequate performance of the duties assigned to each crew member. The procedures foreseen for the execution of descent by instrument have been modified and some have been deleted depending on the appearance of a complicator element (smoke alarm). (4). Influence of the environment – The dark night contributed to the creation of the “black hole” phenomenon, or “background figure”, making it difficult to perceive external references for a possible identification of the vertical distance of the aircraft from the ground. (5). Deficient Oversight – The supervision, at cockpit level, contributed to the accident by the inadequate management of the resources available for the flight in the cockpit. – Company level supervision contributed to the accident by not identifying the need for cockpit management training and providing it to the crew involved. – Supervision, at company level, was also inadequate when climbing to the same mission, two pilots unfamiliar with the airplane to be used and in night operation. (6). Other Operational Aspects – The failure to comply with several “Callouts”, the non-use of the radio altimeter and the inadequate use of the “altitude alert”, as an aid to the accomplishment of the descent procedure, contributed to the occurrence of the accident.

Primary Cause

Combination of human factors (psychological impact and distraction), operational deficiencies (deficient instruction, maintenance, and coordination), and environmental factors (dark night conditions).Combination of human factors (psychological impact and distraction), operational deficiencies (deficient instruction, maintenance, and coordination), and environmental factors (dark night conditions).

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