Incident Overview
Description
Pantanal flight 126 departed Campo Grande (CGR) for a 2 hours and 15 min. flight to Vilhena (BVH). The captain was an instructor, the copilot was receiving line training. The copilot was Pilot Flying (PF). While approaching Vilhena, the weather was reported below minima. Instead of diverting to the alternate airport, the captain decided they should execute an Echo 1 arrival procedure, which was an NDB approach to runway 03. Because actual weather at Vilhena had differed from reported weather conditions in the past, they would descend to MDA. If the runway was not in sight at that point, the approach would be aborted. The copilot inserted an MDA of 2500 feet in the Altitude Alert System. This was an error since the MDA was actually 2560 feet. Both pilot did not notice the error. The instructor told the copilot to monitor the artificial horizon during the final stages of the approach. The copilot focused on the artificial horizon and did not monitor the altimeter. The captain tried to obtain visual contact with the ground, but the city lights were off due to lack of electric energy. He did not call out the altitudes and the airplane did not level off at 2500 feet. The copilot probably shut off or silenced the Altitude Alert System and the airplane continued to descend below MDA. The airplane collided with various trees located to the right and one kilometre short of runway 03. It collided with the ground and skidded to a stop. A fire erupted in the no. 1 engine, spreading to the rest of the airplane. All occupants managed to escape. CONCLUS?O Fator Humano – Aspecto Psicol¢gico – Contribuiu Houve a participa?o de vari veis psicol¢gicas em n¡vel individual, psicossocial e organizacional que interferiram no desempenho dos tripulantes. Fator Operacional (1). Deficiente Coordena?o de Cabine – Contribuiu Houve distribui?o desordenada de tarefas na cabine, com invers?o de atribui?es e canaliza?o de aten?o por parte dos dois pilotos. (2). Condi?es Meteorol¢gicas Adversas – Contribu¡ram O aer¢dromo estava fechado para opera?es por instrumentos e havia forte nevoeiro na regi?o do acidente (setor de aproxima?o). (3). Deficiente Aplica?o de Comando – Indeterminado O aluno estava realizando procedimento de descida por instrumentos utilizando o piloto autom tico e, possivelmente, comandou o desacoplamento deste, fazendo com que a aeronave descesse alm da altitude selecionada no Altitude Select. (4). Indisciplina de Vo – Contribuiu A tripula?o descumpriu intencionalmente regras de tr fego areo previstas no RBHA 121, quando da realiza?o de procedimento de descida com o aer¢dromo operando abaixo dos m¡nimos previstos. (5). Deficiente Julgamento – Contribuiu Houve erro cometido pela tripula?o, decorrente da inadequada avalia?o das condi?es operacionais para a realiza?o do procedimento de descida. (6). Influncia do Meio Ambiente – Contribuiu Houve interferncia do ambiente f¡sico externo cabine, com rela?o falta de energia eltrica na cidade. Os pilotos esperavam encontrar luzes da cidade, no entanto, a falta de energia eltrica causou uma errada sensa?o de posicionamento espacial. (7). Deficiente Planejamento – Contribuiu Houve erro cometido pela tripula?o, em decorrncia de n?o ter planejado adequadamente a fase de aproxima?o para pouso.
Primary Cause
Inadequate coordination of the cabin, resulting in a misdistribution of tasks and a loss of focus among the two pilots. The pilot’s decision to use the automatic descent procedure, coupled with the failure to monitor the altitude, led to the critical error.Inadequate coordination of the cabin, resulting in a misdistribution of tasks and a loss of focus among the two pilots. The pilot’s decision to use the automatic descent procedure, coupled with the failure to monitor the altitude, led to the critical error.Share on:
