Incident Overview

Date: Saturday 7 May 1994
Aircraft Type: Embraer EMB-110EJ Bandeirante
Owner/operator: RICO Taxi A‚reo
Registration Number: PT-GJW
Location: near S?o Gabriel da Cachoeira Airport, AM (SJL) – ÿ Brazil
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 0 / Occupants: 16
Component Affected: Aircraft Flight System (specifically, the pilot’s focus on external references and lack of monitoring)Aircraft Flight System (specifically, the pilot’s focus on external references and lack of monitoring)
Investigating Agency: CENIPACENIPA
Category: Accident
An aircraft incident occurred where a pilot in command adopted improvisational procedures due to weather conditions, leading to a loss of situational awareness and operational control. The pilot?s focus on external references diverted attention from critical flight parameters, resulting in a significant deviation from established procedures. Contributing factors included insufficient simulator training, CRM training, monitoring of the flight parameters, and a lack of adequate oversight during the operation. The small aircraft experience and limited flight experience of the pilot exacerbated these issues, compounded by limited visibility due to degraded navigation aids, ultimately leading to a loss of control and a potential accident.An aircraft incident occurred where a pilot in command adopted improvisational procedures due to weather conditions, leading to a loss of situational awareness and operational control. The pilot?s focus on external references diverted attention from critical flight parameters, resulting in a significant deviation from established procedures. Contributing factors included insufficient simulator training, CRM training, monitoring of the flight parameters, and a lack of adequate oversight during the operation. The small aircraft experience and limited flight experience of the pilot exacerbated these issues, compounded by limited visibility due to degraded navigation aids, ultimately leading to a loss of control and a potential accident.

Description

The aircraft struck trees and crashed short of the runway. The final approach was carried out despite the fact that the airport was closed for IFR operations due to fog. Contributing factors a. Human Factor (1). Psychological Aspect It contributed, since the pilot in command adopted an improvisational attitude through the adoption of unforeseen procedures in the face of the insistence on landing, despite the weather conditions present. A likely channeling of attention to external references may have contributed to the loss of operational performance, leading to the loss of the maintenance condition of the basic flight parameters. (2). Physiological Aspect Undetermined since the absence of interference from toxicological factors was not effectively verified. b. Material Factor Didn’t contribute. c. Operational Factor (1). Deficient Instruction It contributed since there was no periodic simulator training and also no cockpit resource management (CRM) training. (2). Deficient Supervision It contributed since there was no adequate monitoring of the circumstances of operation by the Company’s operations sector and, also, there were no defined and clear rules and specific operating routines that adequately addressed the various aspects of the operation. (3). Little Flight or Aircraft Experience It contributed because of the small experience in the aircraft by the copilot. (4). Influence of the Environment It contributed since visibility was limited at the time of the accident. (5). Deficient Cockpit Coordination Contributed since there was no briefing to the accomplishment of the descent procedure by instruments, the copilot did not follow the execution of the procedures after the critical point since he concentrated his attention to the search of external references, thus abandoning the monitoring of the flight parameters. (6). Disabled Infrastructure Indetermined since the influence of the low accuracy of the NDB on the heading lags occurred in the descent procedure was not perfectly established and no effective test was performed. (7). Poor Planning It contributed because there was no briefing in the procedure of descent by instrument and approach lost. (8). Deficient discipline of Flight The pilot therefore continued the flight, without visibility, at an altitude below the minimum for this operating condition. (9). Adverse Weather Conditions It contributed as the prevailing weather conditions were marginal, with the aerodrome closed for IFR operation.

Primary Cause

Improvised Procedural Actions and Lack of OversightImprovised Procedural Actions and Lack of Oversight

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