Incident Overview

Date: Wednesday 6 June 2012
Aircraft Type: Swearingen SA227-AC Metro III
Owner/operator: Air Class L¡neas A‚reas
Registration Number: CX-LAS
Location: 1,5 km S off Isla de Flores, Rio de la Plata – ÿ Uruguay
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 2
Component Affected: Navigation Instruments (Inverters)Navigation Instruments (Inverters)
Investigating Agency: CIAIACIAIA
Category: Accident
A Swearingen SA227AC Metro III cargo aircraft experienced a catastrophic accident on July 20, 2012, resulting in the deaths of both pilots. The aircraft impacted the waters of the Rio de la Plata, and the wreckage was located approximately 8 feet deep south of Isla de Flores. Investigation revealed a series of contributing factors leading to the accident, including pilot error, instrument malfunction, inadequate weather information, lack of procedural adherence, and potential system failures. The aircraft?s flight path, including a left-hand turn, was compounded by a failure to properly assess situational awareness and the presence of potential ice formation. The pilot?s actions, including an incorrect course change, a lack of awareness of the situation, and reliance on outdated information, contributed to the accident. The failure to energize the Navigation Instruments, particularly the inverters, was a critical factor.A Swearingen SA227AC Metro III cargo aircraft experienced a catastrophic accident on July 20, 2012, resulting in the deaths of both pilots. The aircraft impacted the waters of the Rio de la Plata, and the wreckage was located approximately 8 feet deep south of Isla de Flores. Investigation revealed a series of contributing factors leading to the accident, including pilot error, instrument malfunction, inadequate weather information, lack of procedural adherence, and potential system failures. The aircraft?s flight path, including a left-hand turn, was compounded by a failure to properly assess situational awareness and the presence of potential ice formation. The pilot?s actions, including an incorrect course change, a lack of awareness of the situation, and reliance on outdated information, contributed to the accident. The failure to energize the Navigation Instruments, particularly the inverters, was a critical factor.

Description

A Swearingen SA227AC Metro III cargo impacted the waters of the Rio de la Plata during a flight from Montevideo-Carrasco Airport (MVD) to Buenos Aires/Ezeiza, Argentina. The wreckage was located on July 20, 2012 in 8 feet deep water south off Isla de Flores. Both pilots were killed. The flight took off about 19:55 from runway 06 at Montevideo. While climbing to the assigned altitude of FL80 the airplane entered a left hand turn. The controller contacted the flight. The crew replied they would change course to the SARGO waypoint. This was the last contact with the flight. Probable Cause Loss of Control of the Aircraft due to being flying with erroneous indications of the flight instruments, added to the possible formation of crystalline ice on its structure, causing a loss of situational awareness of the crew. Contributing factors – Lack of Aeronautical Weather information for the area at the time of Operation. – Lack of confidence in the Meteorological Radar of the Aircraft (the PF had made several notes in the RTV about its operability). – According to the different analyses, it could be determined that the 115 Volts A.C. electrical system was not energized, so it is presumed that the checklist was not performed correctly in different procedures, which led to the avoidance of control items for the operation of navigation instruments. (The ignition control of the inverters is marked with an asterisk in the aircraft checklists, which determines that the item must be performed with the assistance of the NFP) . – The PF had made its last five flights in another aircraft (CX-CLS), in which although it is the same model as the accident, the inverters do not energize the Navigation Instruments. – The Flight Plan presented showed the CX-CLS aircraft as planned to perform the Mission. – TWR request for take-off before the time determined by the flight plan. – The taxiing was too fast, which conditioned the correct checking of the checklists for takeoff. – Not recognizing the failure of Instruments, motivated to make a turn that diverted the Aircraft from the route and directed it towards a Cloud System with Freezing conditions. – Not realizing the possible formation of crystalline ice in the structure of the aircraft, making a turn that aggravated the situation. – Possible overconfidence of the PF accompanied by the short experience of the PNF and the lack of an interactive CRM. – Possible blockage of the static pitot system, which would generate erroneous indications of speed, height and attitude. – Possible loss of situational awareness (perception of self and aircraft in relation to dynamic flight environment and threats, with ability to predict what will happen based on perception) – By not energizing the Flight System, the Artificial Horizon Instrument (ADI) model installed in the Aircraft gives a permanent ascent indication. This model of instrument does not have an indication flag when it is out of operation, the inoperability of the instrument is indicated at the bottom of the instrument where there is a bar that only changes color from red (out of operation) to black (operational). – Maintaining a flight with speeds above the VMO, a situation aggravated by a turn; being in weather conditions where speed must be reduced to maintain control of the aircraft. – Location of a GPS not enabled in a position that could confuse the crew for its luminosity.

Source of Information

http://www.elobservador.com.uy/noticia/225562/desaparecio-un-avion-civil-que-volaba-desde-carrasco-hacia-ezeiza/, http://ifronline.blogspot.com.br/2012/06/aviao-desaparece-no-rio-da-prata-e-ha.htmlhttp://www.elobservador.com.uy/noticia/225562/desaparecio-un-avion-civil-que-volaba-desde-carrasco-hacia-ezeiza/, http://ifronline.blogspot.com.br/2012/06/aviao-desaparece-no-rio-da-prata-e-ha.html

Primary Cause

Failure to energize Navigation Instruments (Inverters) due to checklist errors and lack of operational awareness.Failure to energize Navigation Instruments (Inverters) due to checklist errors and lack of operational awareness.

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