Incident Overview

Date: Friday 13 September 1996
Aircraft Type: Embraer EMB-110 Bandeirante
Owner/operator: Helisul Taxi A‚reo
Registration Number: PT-WAV
Location: NW of Joinville, SC – ÿ Brazil
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 2
Component Affected: Aircraft Systems ? Specifically, the aircraft’s descent control system and the instrument systems responsible for navigation and altitude monitoring.Aircraft Systems ? Specifically, the aircraft’s descent control system and the instrument systems responsible for navigation and altitude monitoring.
Investigating Agency: CENIPACENIPA
Category: Accident
On October 26, 2023, a Bandeirante cargo aircraft, en route from Porto Alegre (POA) to Joinville (JOI), experienced an unforecasted flight. The initial part of the flight was uneventful. The aircraft was cleared for an Echo 1 arrival, involving a turn to QDR 356 degrees over the NDB beacon, heading towards the PP NDB. The minimum descent altitude was 770 feet. The PP NDB was inoperative at the time of the accident. Upon reaching the PP NDB, the crew selected PP. However, due to the inoperable beacon, their instruments indicated a heading of 051 degrees towards the PP beacon at S?o Paulo-Congonhas. The crew did not notice the incorrect heading. They continued their descent below the minimum descent altitude and collided with a hill at an altitude of 300 feet. This collision resulted in significant damage to the aircraft.On October 26, 2023, a Bandeirante cargo aircraft, en route from Porto Alegre (POA) to Joinville (JOI), experienced an unforecasted flight. The initial part of the flight was uneventful. The aircraft was cleared for an Echo 1 arrival, involving a turn to QDR 356 degrees over the NDB beacon, heading towards the PP NDB. The minimum descent altitude was 770 feet. The PP NDB was inoperative at the time of the accident. Upon reaching the PP NDB, the crew selected PP. However, due to the inoperable beacon, their instruments indicated a heading of 051 degrees towards the PP beacon at S?o Paulo-Congonhas. The crew did not notice the incorrect heading. They continued their descent below the minimum descent altitude and collided with a hill at an altitude of 300 feet. This collision resulted in significant damage to the aircraft.

Description

The Bandeirante cargo plane departed Porto Alegre (POA) at 20:45 on a flight to Joinville (JOI). The en route part of the flight was uneventful. The airplane was cleared for a Echo 1 arrival, which included turning to QDR 356 degrees over the JNV NDB beacon, heading towards the PP NDB. The minimum descent altitude was 770 feet. The PP NDB was inoperative at the time of the accident. Over the JNV beacon the crew selected PP. Because this beacon was inoperative, their instruments indicated a heading of 051 degrees towards the PP beacon at S?o Paulo-Congonhas. The crew did not notice the incorrect heading. They continued their descent below MDA and collided with a hill at an altitude of 300 feet. CONCLUS?O Fator Humano (1) Aspecto Fisiol¢gico – Indeterminado.  poss¡vel que tenha havido a interferˆncia de vari veis f¡sicas, com rela‡?o … fadiga de v“o, que interferiram no desempenho da tripula‡?o. (2) Aspecto Psicol¢gico – Indeterminado.  poss¡vel que tenha havido a participa‡?o de vari veis psicol¢gicas a n¡vel individual e organizacional que interferiram no desempenho da tripula‡?o na atividade a‚rea. Fator Operacional (1) Deficiente Supervis?o – Indeterminado.  poss¡vel que a inadequada supervis?o da empresa no planejamento do v“o, com rela‡?o ao descumprimento de lei de regulamenta‡?o, tenha contribu¡do para a ocorrˆncia do acidente, considerando-se a fadiga da tripula‡?o. (2) Deficiente Coordena‡?o de Cabine – Contribuiu. Houve erro cometido pela tripula‡?o em decorrˆncia da inadequada utiliza‡?o de recursos dispon¡veis na cabine, com rela‡?o … n?o realiza‡?o do procedimento de descida padr?o. (3) Deficiente Julgamento – Indeterminado.  poss¡vel que tenha havido erro cometido pela tripula‡?o em decorrˆncia da inadequada avalia‡?o do procedimento de descida. (4) Indisciplina de V“o – Indeterminado.  poss¡vel que tenha havido desobediˆncia intencional pela tripula‡?o da Lei 7183, art. 36, com rela‡?o ao per¡odo m¡nimo de descanso entre etapas de v“os noturnos.  poss¡vel, tamb‚m, que tenha havido desobediˆncia intencional pela tripula‡?o de regras de tr fego a‚reo e normas operacionais, com rela‡?o … utiliza‡?o de equipamento GPS para a realiza‡?o de procedimento de descida, mesmo n?o estando homologado para tal.

Primary Cause

Deficient Supervision ? The inadequate supervision of the company in planning the flight, particularly concerning the crew’s exemption of regulations, contributed to the accident.Deficient Supervision ? The inadequate supervision of the company in planning the flight, particularly concerning the crew’s exemption of regulations, contributed to the accident.

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