Incident Overview

Date: Monday 3 February 1992
Aircraft Type: Embraer EMB-110C Bandeirante
Owner/operator: Nordeste Linhas A‚reas
Registration Number: PT-TBB
Location: Caetit‚, BA – ÿ Brazil
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 12 / Occupants: 12
Component Affected: Bandeirante AircraftBandeirante Aircraft
Investigating Agency: CENIPACENIPA
Category: Accident
A Bandeirante aircraft descended below the Minimum Altitude (MDA) due to adverse weather conditions, impacting Taquari Hill at a height of 3400 feet. The hill was obscured by clouds, contributing to the incident. The pilot’s actions, including dropping below the safety altitude and failing to adequately prepare for the flight, resulted in a significant risk. A lack of proper planning, inadequate supervision, and compliance with established procedures exacerbated the situation.A Bandeirante aircraft descended below the Minimum Altitude (MDA) due to adverse weather conditions, impacting Taquari Hill at a height of 3400 feet. The hill was obscured by clouds, contributing to the incident. The pilot’s actions, including dropping below the safety altitude and failing to adequately prepare for the flight, resulted in a significant risk. A lack of proper planning, inadequate supervision, and compliance with established procedures exacerbated the situation.

Description

The Bandeirante descended below MDA in bad weather and impacted Taquari Hill at 3400 feet. The hill was hidden by clouds. Contributing factors a. Human Factor (1). Physiological Aspect – Did not contribute. (2). Psychological Aspect – Undetermined. b. Material Factor – Did not contribute. c. Operational Factor (1). Adverse Weather Conditions – Weather conditions along the entire route and in the area where the accident occurred were adverse to maintain visual flight. (2). Disabled Judgement – The pilot dropped below the region’s safety altitude, (5000 feet) when flying in instrument flight conditions. (3). Poor Planning – There was an inadequate preparation for the flight, the pilot did not plan his navigation accurately in relation to his speed, height, distance and time. (4). Disabled Supervision – The company had no mechanisms and instruments for monitoring personnel, making it impossible to record and correct the performance deficiencies presented. (5). Other Operational Aspects – The crew did not comply with the procedure adopted by the company in the Salvador /Guanambi route, unnecessarily increasing the risk margin. (6). Others – Possibility of deficiencies in organizational processes such as management, recruitment and selection, training and monitoring of personnel.

Primary Cause

Adverse Weather ConditionsAdverse Weather Conditions

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