Incident Overview

Date: Thursday 20 September 1990
Aircraft Type: Embraer EMB-110P1 Bandeirante
Owner/operator: Governo do Estado de Pernambuco
Registration Number: PT-FAW
Location: off Fernando de Noronha Airport, FN (FEN) – ÿ Brazil
Phase of Flight: Initial climb
Status: Destroyed, written off
Casualties: Fatalities: 12 / Occupants: 12
Component Affected: Embraer 110 PT-FAW AircraftEmbraer 110 PT-FAW Aircraft
Investigating Agency: CENIPACENIPA
Category: Accident
On March 17, 2024, an Embraer 110 PT-FAW aircraft, en route from Fernando de Noronha to Recife, Brazil, experienced a sudden and significant deterioration following the initial engine start. The aircraft was readied for a flight at 30 minutes, and the crew initiated takeoff immediately. However, the engines were started again within just 30 minutes of departure, leading to a rapid and unexpected descent into the sea. Investigation revealed that both pilots possessed limited experience with the Bandeirante aircraft and had not flown it in 141 days and 133 days prior to the incident. The aircraft took off from runway 12, entered a steep climb, and subsequently veered sharply to the right, culminating in a dive into the ocean. The incident highlights a combination of human factors, physiological limitations, operational deficiencies, and environmental factors.On March 17, 2024, an Embraer 110 PT-FAW aircraft, en route from Fernando de Noronha to Recife, Brazil, experienced a sudden and significant deterioration following the initial engine start. The aircraft was readied for a flight at 30 minutes, and the crew initiated takeoff immediately. However, the engines were started again within just 30 minutes of departure, leading to a rapid and unexpected descent into the sea. Investigation revealed that both pilots possessed limited experience with the Bandeirante aircraft and had not flown it in 141 days and 133 days prior to the incident. The aircraft took off from runway 12, entered a steep climb, and subsequently veered sharply to the right, culminating in a dive into the ocean. The incident highlights a combination of human factors, physiological limitations, operational deficiencies, and environmental factors.

Description

Embraer 110 PT-FAW was being readied for a flight from the Fernando De Noronha Archipelago (FEN) to Recife (REC) on the mainland of Brazil. The aircraft had been on the ground for just 30 minutes when the engines were started again. The pre-departure checks were carried out by the first officer, while the captain arrived in a hurry. The aircraft was taxied out immediately and it is presumed that the crew did not carry out the pre-takeoff checklist. The airplane took off from runway 12, entered a steep climb and turned right. Shortly afterwards the airplane was seen to dive into the sea. Investigation revealed that both pilots had very little experience on Bandeirante planes. Also, they had not flown such a plane in 141 (captain) and 133 days (first officer) days. CONCLUSION: Human Factor (1) Physiological Aspect – Undetermined There are indications of the contribution of this aspect with regard to the spatial disorientation of the crew. (2) Psychological Aspect – Contributed To the extent that the organization was not equipped with effective systems for monitoring and training of personnel. Operational Factor (1). Deficient Instruction – Contributed For qualitative and quantitative deficiency of instruction, not attributing technical conditions necessary for the performance of the air activity. (2). Deficient Maintenance – Contributed The inadequacy of the corrective services performed on the aircraft. (3). Deficient Application in the Command – Contributed For the crew’s ineptitude to allow the aircraft to engage in abnormal behavior. (4). Deficient Cockpit Co-ordination – Contributed The inadequate use of cockpit resources for the operation of the aircraft, and also failure to comply with operational standards. (5). Influence of the Environment – Contributed By the intrinsic characteristic of Fernando de Noronha aerodrome, as capable of causing spatial disorientation. (6). Deficient – contributed The inadequate assessment of certain operational aspects during the mission and the use of own piloting standards (7). Little Flight Experience in the Aircraft – Contributed For the reduced average of 44:00h of flight for the pilot and 73:00h for the co-pilot and, also, the crew leave for more than 120 days of air activity. (8). Deficient Supervision – Contributed The lack of supervision of the Air Transport Division in relation to planning and operational maintenance of its pilots, creating an undesirable climate of complacency in the organization. (9). Other Operational Aspects – Contributed By the intentional and unnecessary increase of the risk margin, when the pilots are not properly readapted, provided for in the RBHA-61, leaving the crew disqualified for the mission.

Primary Cause

Insufficient training and experience of the pilots, coupled with inadequate oversight and preparation, exacerbated the situation.Insufficient training and experience of the pilots, coupled with inadequate oversight and preparation, exacerbated the situation.

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