Incident Overview

Description
The Embraer Brasilia landed at Manaus-Eduardo Gomes International Airport in Brazil and taxied to the platform. The flight crew feathered the propellers and applied the brakes as they wanted to stop the aircraft. There was no deceleration after both captain and co-pilot used the brakes. The co-pilot suggested to use reverse thrust, but the propellers were already feathered. In an attempt to avoid impact against a building ahead, the pilot turned the aircraft to the left. The emergency brake was applied; however, by that time the aircraft collided with another brick building. On impact, the left propeller and engine were damage, and the right landing gear fell into a drainage ditch, approximately one meter deep. All occupants were unhurt. 1 Human Factor Operational Aspect a. Training – Contributed The crew did not have sufficient training to enable the desired assertiveness for the correct use of aircraft resources, which would probably have prevented the accident, since, instead of applying the emergency brake, they applied reverse with the feathered props, contrary to the procedure provided for in the Aircraft Manual. b. Maintenance – Contributed The maintenance services were not efficient, as they did not comply with the Aircraft Maintenance Manual in relation to the dimensional adjustment of the Hub Cap Drive Clips’ drive clips, and the Service Bulletin incorporated stickers to the outer doors of the main landing gear, as a reminder to the mechanic to check the clearances. c. Application of the Commands – Contributed The co-pilot failed to apply the reverse pitch on the propellers as they were feathered, and at that moment the emergency brake should be commanded to brake the aircraft. d. Supervision – Contributed The company failed to adequately check the execution of the actions provided for in the Aircraft Maintenance Manual regarding the “Anti-Skid” system and to verify the application of all service bulletins issued by the manufacturer. 2 Material Factor Did not contribute.
Primary Cause
Insufficient Crew Training and Lack of Procedural AdherenceInsufficient Crew Training and Lack of Procedural AdherenceShare on: