Incident Overview

Date: Monday 11 November 1991
Aircraft Type: Embraer EMB-110P1 Bandeirante
Owner/operator: Nordeste Linhas A‚reas
Registration Number: PT-SCU
Location: 0,5 km NE of Recife-Guararapes International Airport, PE (REC) – ÿ Brazil
Phase of Flight: Initial climb
Status: Destroyed, written off
Casualties: Fatalities: 15 / Occupants: 15
Component Affected: Right Hand Engine, T5 Bus Bar Assembly, Compressor Turbine Stator Assembly (CT Vane Ring), Flight Data RecorderRight Hand Engine, T5 Bus Bar Assembly, Compressor Turbine Stator Assembly (CT Vane Ring), Flight Data Recorder
Investigating Agency: CENIPACENIPA
Category: Accident
The Bandeirante incident involved a catastrophic takeoff due to a series of failures stemming from pilot error, inadequate training, maintenance deficiencies, and operational lapses. The engine failure triggered a fire, resulting in a significant impact with surrounding property. The faulty engine temperature indicator exacerbated the situation, leading to a rapid and uncontrolled descent. The aircraft subsequently collided with residences, causing substantial damage. The investigation revealed a complex interplay of factors, including pilot decision-making errors, inadequate emergency procedures, and insufficient oversight. The initial failure of the T5 Bus Bar Assembly, coupled with subsequent manufacturing and maintenance issues, directly contributed to the severity of the accident. The pilot’s delayed response to the emergency, compounded by the lack of proper training and monitoring, significantly worsened the situation. The investigation also highlighted a lapse in oversight regarding maintenance practices and the absence of adequate safety checks.The Bandeirante incident involved a catastrophic takeoff due to a series of failures stemming from pilot error, inadequate training, maintenance deficiencies, and operational lapses. The engine failure triggered a fire, resulting in a significant impact with surrounding property. The faulty engine temperature indicator exacerbated the situation, leading to a rapid and uncontrolled descent. The aircraft subsequently collided with residences, causing substantial damage. The investigation revealed a complex interplay of factors, including pilot decision-making errors, inadequate emergency procedures, and insufficient oversight. The initial failure of the T5 Bus Bar Assembly, coupled with subsequent manufacturing and maintenance issues, directly contributed to the severity of the accident. The pilot’s delayed response to the emergency, compounded by the lack of proper training and monitoring, significantly worsened the situation. The investigation also highlighted a lapse in oversight regarding maintenance practices and the absence of adequate safety checks.

Description

The Bandeirante was piloted by a DAC check pilot and a co-pilot from Nordeste. During takeoff the right engine suffered a failure. A fire erupted immediately. Takeoff was continued and the airplane rotated after 900 m instead of the usual 570 m. The Bandeirante barely climbed and then another bang was heard. Flaming debris fell from the right hand engine, setting fire to an area within the airport perimeter fence. The airplane climbed to a height of 30 m and yawed to the right. The flight crew applied the wrong technique to counter the yaw. Some thirty seconds after takeoff the aircraft collided with two residences and crashed onto a public square. It was determined that the temperature indicator for the right hand engine was faulty, displaying a lower than actual temperature. The engine operated for some time at high temperatures because of the faulty system. It was also found that, after completion, some maintenance and inspection tasks were just signed by the maintenance engineer. Signatures from the maintenance inspector were missing. CONCLUSION: Human Factor – Psychological Aspect – Contributed At the individual level, the delay in the decision making of the pilots as to the appropriate procedures for that emergency situation. At the organizational level, the lack of adequate training for emergency situations and the absence of activities to prevent aviation accidents in the company. Material Factor (1) Project Deficiency – Contributed The “T5 Bus Bar Assembly” set, specifically the Bus Bar’s insulation and fastening system, proved to be deficient. The detachment of their insulation gloves had the double consequence of causing erroneous TIT indication and clogging of the vanes’ cooling holes, aggravated by the maintenance aspect. (2) Manufacturing Deficiency – Contributed There was a deficiency in the process of casting the compressor turbine stator assembly (CT Vane Ring), generating fins with wall thicknesses different from those predicted in the design. Operational Factor (1) Poor Application of Commands – Undetermined This factor was not fully characterized due to the inexistence of flight data recorders that could confirm their participation. The pilot could have compensated the rudder to the wrong side after the engine failure or the rudder compensator could already be in the wrong compensation to counteract the yaw tendency of the aircraft. (2) Poor Maintenance – Contributed Due to the notoriety of the facts and evidence raised in the investigation, there was a failure by the company during the HSI (Hot Section Inspection), when the limits of CT Vane Ring cracks were not observed. (3) Poor Instruction – Contributed The company did not meet the minimum requirements for crew members to operate the aircraft properly in emergency situations, as required by RBHA 135. (4) Poor Supervision – Present and Indeterminate Contribution. The company did not comply with aviation standards in order to supervise the execution of the maintenance services performed. (5) Poor Judgment – Contributed The takeoff could and should have been aborted by the pilot in command. (6) Influence of the Environment – Undetermined The take-off was carried out at night time and, considering the particularities of this situation, it was possible that the environment contributed negatively to the pilot’s judgment, by choosing to continue the takeoff.

Primary Cause

Faulty Engine Temperature Indicator and SystemFaulty Engine Temperature Indicator and System

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