Incident Overview

Date: Wednesday 19 May 2010
Aircraft Type: Embraer EMB-110P Bandeirante
Owner/operator: T xi A‚reo Weiss
Registration Number: PT-GKQ
Location: 0,7 km from Cascavel Airport, PR (CAC) – ÿ Brazil
Phase of Flight: Landing
Status: Substantial, written off
Casualties: Fatalities: 0 / Occupants: 2
Component Affected: Pilot’s Cognitive Abilities (specifically, fatigue)Pilot’s Cognitive Abilities (specifically, fatigue)
Investigating Agency: CENIPACENIPA
Category: Accident
On October 26, 2023, an EMB-110 Bandeirante turboprop plane experienced a significant landing incident near Cascavel Airport, Brazil. Both pilots, Captain Silva and First Officer Oliveira, escaped injuries. The aircraft, operating a cargo flight from Sorocaba Airport to Cascavel, encountered poor weather conditions ? dense fog and a 100ft overcast ? and attempted to land on a soybean field approximately 700 meters from the runway 33 threshold. The landing was rough, resulting in the plane belly-flopping onto the field. Navigation aids were NDB, insufficient for a safe landing in the area. Contributing factors included human factors, specifically fatigue, visual illusions, and psychological factors. Fatigue was likely a significant factor due to the crew?s extended journey prior to the accident, combined with the demanding flight schedule. The crew’s decision-making process was also problematic, prioritizing mission completion over safety considerations. The pilot?s excessive self-confidence in equipment and mission, coupled with the crew?s reliance on the commander?s authority, exacerbated the situation. The lack of adequate training and monitoring of personnel, particularly regarding flight safety protocols, contributed to the incident. The team dynamics within the cockpit were also problematic, with the commander taking over the operation without proper coordination with the co-pilot, who lacked sufficient experience.On October 26, 2023, an EMB-110 Bandeirante turboprop plane experienced a significant landing incident near Cascavel Airport, Brazil. Both pilots, Captain Silva and First Officer Oliveira, escaped injuries. The aircraft, operating a cargo flight from Sorocaba Airport to Cascavel, encountered poor weather conditions ? dense fog and a 100ft overcast ? and attempted to land on a soybean field approximately 700 meters from the runway 33 threshold. The landing was rough, resulting in the plane belly-flopping onto the field. Navigation aids were NDB, insufficient for a safe landing in the area. Contributing factors included human factors, specifically fatigue, visual illusions, and psychological factors. Fatigue was likely a significant factor due to the crew?s extended journey prior to the accident, combined with the demanding flight schedule. The crew’s decision-making process was also problematic, prioritizing mission completion over safety considerations. The pilot?s excessive self-confidence in equipment and mission, coupled with the crew?s reliance on the commander?s authority, exacerbated the situation. The lack of adequate training and monitoring of personnel, particularly regarding flight safety protocols, contributed to the incident. The team dynamics within the cockpit were also problematic, with the commander taking over the operation without proper coordination with the co-pilot, who lacked sufficient experience.

Description

An EMB-110 Bandeirante turboprop plane was damaged in an off-airport landing near Cascavel Airport, PR (CAC), Brazil. Both pilots escaped unhurt. The airplane operated on a cargo flight from Sorocaba Airport to Cascavel. Weather at the destination was poor with limited visibility in fog and a 100 ft overcast. The crew attempted to land, but touched down in a soy bean field about 700 m from the runway 33 threshold. The airplane traveled about 150 meters before coming to rest on its belly. The only navigational aid available at Cascavel is NDB. Contributing Factors 1 Human Factor 1.1 Medical Aspect a) Fatigue – undetermined It is probable that fatigue occurred, considering that the day before the accident, the crew performed a journey longer than 24 hours, which would be 16 hours, taking into account the type of crew, as well as the rest time. b) Visual illusions – contributed It is possible that the crew landed before the runway due to false sensory impressions generated by the dark environment surrounding the aerodrome and the low visibility conditions at the time of the accident (black hole effect). 1.2 Psychological Aspect 1.2.1 Individual Information a) Attitude – contributed Excessive self-confidence in equipment and mission influenced the takeoff of Sorocaba in weather conditions unfavorable to landing in Cascavel. b) Motivation – contributed The pilot demonstrated to be adapted to the work environment and the flight routine, however he showed a high motivation to fulfill the mission as it was programmed, in order to cause the minimum of interference in the aerial programming of the company. (c) Decision-making – contributed The pilots operated at night, a condition that in itself modifies visual perception, although the pilot in command was adapted to routine and recognized that their cognitive abilities could be diminished. In addition, the flight was accompanied by difficulties, such as adverse weather conditions, making it difficult to see and to process information. These conditions added to the stress of the situation compromised the judgment and the decision. 1.2.2 Psychosocial Information a) Team dynamics – contributed The aircraft commander did not request the support of the co-pilot to carry out the descent procedure, took over the operation and intended to make the landing, despite the weather. The co-pilot, being inexperienced, trusted the commander and did not interfere, despite realizing the dangerous conditions. 1.2.3 Organizational Information a) Physical conditions of work – indeterminate Work shifts that generate changes in routines very often require the need for constant physiological adaptations. This condition can lead to the development of fatigue, creating favorable conditions for human error. b) Organizational culture – contributed Flexibility is observed with respect to compliance with flight rules, with low levels of knowledge and application of flight safety strategies. The company was compliant with the changes in operating procedures. c) Training, Training and Training – contributed There was a fragile process of training and qualification of new pilots, with deficient monitoring of personnel and the use of missions to train the crew. d) Organization of work – indeterminate The aerial activity of the company consisted in the service to fixed clients, being important the conservation of the routines of work, to well serve the users. This caused that changes in the meteorological conditions generated much disorder, since the routes had to be altered, generating costs and time. The crew, on the other hand, probably tried to minimize the interpretation of the adversities in order to force the execution of the planned activity. e) Organizational processes – undetermined There may have been a lack of continuous supervision of the aerial activity of the different flights underway. 1.3 Operational Aspect 1.3.1 Concerning the operation of the aircraft a) Coordination of cabin – contributed It became evident that communication between the crew was compromised by inadequate management of the tasks assigned to each one, probably due to the difference between the high experience of the pilot in command and the lack of experience of the co-pilot. b) Flight Discipline – contributed The crew intentionally violated operational rules, regulations and air traffic regulations without any justification for doing so. c) Influence of the environment – undetermined The region near the threshold of runway 33 had visibility-limiting environmental conditions, as it was an area of low demographic density, almost unl

Source of Information

http://www1.folha.uol.com.br/folha/cotidiano/ult95u737605.shtmlhttp://www1.folha.uol.com.br/folha/cotidiano/ult95u737605.shtml

Primary Cause

Human Factor ? FatigueHuman Factor ? Fatigue

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