Incident Overview

Date: Wednesday 6 June 1990
Aircraft Type: Fairchild FH-227B
Owner/operator: TABA – Transportes A‚reos da Bacia Amaz“nica
Registration Number: PT-ICA
Location: 0,8 km from Altamira Airport, PA (ATM) – ÿ Brazil
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 22 / Occupants: 42
Component Affected: Aircraft (specifically, the aircraft’s flight control systems, navigation equipment, and the aircraft’s ability to maintain a visual approach).Aircraft (specifically, the aircraft’s flight control systems, navigation equipment, and the aircraft’s ability to maintain a visual approach).
Category: Accident
On June 5, 1990, a flight from Bel‚m to Cuiab , involving a total of 4,5 hours in a 24-hour timeframe, was marred by a captain’s abrupt return to work after a period of residence. The captain, despite a poor mood, resumed work, leading to a hazardous landing. The aircraft entered the downwind leg, colliding with trees and resulting in a significant crash. The fog bank approaching the runway presented a significant challenge, and the captain’s reliance on visual approach, combined with a lack of awareness of the fog, contributed to the accident.On June 5, 1990, a flight from Bel‚m to Cuiab , involving a total of 4,5 hours in a 24-hour timeframe, was marred by a captain’s abrupt return to work after a period of residence. The captain, despite a poor mood, resumed work, leading to a hazardous landing. The aircraft entered the downwind leg, colliding with trees and resulting in a significant crash. The fog bank approaching the runway presented a significant challenge, and the captain’s reliance on visual approach, combined with a lack of awareness of the fog, contributed to the accident.

Description

On June 5, 1990 the captain flew a total of 4,5 hours in a 24-hour timeframe on flights TAB 814/815. Instead of resting, the captain worked in the house from 09:50 until at least 21:30. After sleeping for five hours at most, the captain, in a bad mood, returned to work. The TABA flight on June 6 departed early in the morning from Bel‚m (BEL) on a scheduled flight to Cuiab  (CGB). Intermediate stops were planned at Altamira (ATM), Santar‚m (STM), Itaituba (ITB) and Alta Foresta (AFL). Night-time IFR conditions existed as the flight approached Altamira. TABA pilots were familiar with a fog bank in the approach path to runway 07. It was common practice for pilots to fly a visual approach and being lined up and stabilized for landing, they entered the fog bank in the expectation that near the threshold they would find visual conditions again. In this case the captain also cancelled IFR and continued VFR. The aircraft entered in the downwind leg and, in normal conditions, it turned base, informing the Altamira Radio that the gear was lowered. The FH-227 descended below the approach path. It collided with trees and crashed 850 meters short of the runway. CONCLUS?O: Fator Humano (1). Aspecto Fisiol¢gico – Contribuiu O comandante havia voado 4,5 horas nas £ltimas 24 horas. Durante parte desse per¡odo, realizou obras em sua residˆncia. Seu £ltimo per¡odo de sono foi inferior a cinco horas. (2). Aspecto Psicol¢gico – Contribuiu O comandante atravessava um per¡odo em que demonstrava aborrecimento, agressividade e desmotiva‡?o, relaxando, por sua vez, em sua padroniza‡?o. Apesar de ser imponder vel a interferˆncia deste quadro em seu desempenho, ‚ certo que seu racioc¡nio foi dificultado pela falha da informa‡?o acerca da presen‡a de nevoeiro, pr¢ximo … cabeceira da pista, e pelo prov vel alongamento da perna do vento, comprometendo a vari vel tempo e o processo de decis?o de suma importƒncia nessa fase de opera‡?o. Fator Operacional (1). Condi‡?es Meteorol¢gicas Adversas – Contribu¡ram Independentemente de ter ocorrido uma hip¢tese ou outra, este fator foi determinante no desenrolar dos fatos. (2). Deficiente Julgamento – Contribuiu Em qualquer das hip¢teses, o comandante avaliou erradamente a situa‡?o e os fatos que a envolviam. (3). Deficiente Planejamento – Contribuiu O piloto, por ser bem experiente na aeronave e profundo conhecedor da regi?o, deveria estar mais bem preparado para enfrentar a situa‡?o que se lhe apresentava. A arremetida com o pouso na pista oposta deveria constar, prioritariamente, em seu planejamento. (4). Esquecimento – Indeterminado Os pilotos podem ter esquecido de cronometrar o tempo de deslocamento na perna do vento, acarretando o seu alongamento. (5) Indisciplina de v“o – Contribuiu Houve desobediˆncia das regras de tr fego a‚reo. (6) Influˆncia do Meio Ambiente – Contribuiu A regi?o ‚ prop¡cia … forma‡?o de nevoeiros devido …s suas caracter¡sticas fisiogr ficas, principalmente nesta ‚poca do ano. (7) Deficiente Pessoal de Apoio – Contribuiu Na medida em que as informa‡?es dadas pelo pessoal da esta‡?o r dio s?o em n¡vel de assessoramento, n?o tendo um car ter mandat¢rio. No acidente em quest?o, o funcion rio que fazia a fonia n?o teve condi‡?es t‚cnicas de fornecer mais detalhes da meteorologia reinante e nem mesmo percebeu que havia nevoeiro na aproxima‡?o final. Assim sendo, o piloto, que estava efetuando um tr fego visual, entrou inesperadamente no nevoeiro.

Primary Cause

Poor judgment, inadequate planning, and a failure to adequately assess and mitigate weather conditions, particularly the presence of fog and the potential for a prolonged leg of the wind.Poor judgment, inadequate planning, and a failure to adequately assess and mitigate weather conditions, particularly the presence of fog and the potential for a prolonged leg of the wind.

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