sábado, 7 de setembro de 2024

VOEPASS 2283 [PASSAREDO CALLSIGN] PRELIMINARY REPORT - LOSS OF CONTROL IN-FLIGHT (LOC-I)

 




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SOURCE: CENIPA

LOC-I LOSS OF CONTROL IN-FLIGHT

Date: 9 August 2024

(UTC): 9 August 2024

Time: 16:22

City: VINHEDO - SÄO PAULO - BRASIL

Aerodrome: OUTSIDE THE AERODROME

Local: RESIDENTIAL AREA OF THE CITY

Damage to third

parties: YES

Injuries Function on Board Quantity

FATAL CREW 4

FATAL PASSENGERS 58

 

History

 

At 14:58 UTC, the aircraft took off from SBCA (Coronel Adalberto Mendes da Silva Airport, Cascavel, State of Paraná), bound for SBGR (Guarulhos - Governador André Franco Montoro - Airport, Guarulhos, State Of SOO Paulo) on a public regular passenger transport flight with 04 crew and 58 passengers on board. With the aircraft flying along the route, and after encountering icing conditions, control Of the aircraft was lost and it crashed into the ground.

 

Aircraft Involved

Registration marks: PSVPB

Location of latest takeoff: SBCA - ADALBERTO MENDES DA SILVA

Location of intended landing: SBGR - GOVERNADOR ANDRÉ FRANCO MONTORO

Type of operation: REGULAR

Phase of flight: CRUISE

Aircraft damage: DESTROYED

 

Sequence of events

Based on the information collected at the initial field Investigation, as well as recordings from the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR), the Investigation Committee identified the sequence of events preceding the aircraft's collision with the ground. The time reference utilized is UTC (Universal Time Coordinated).

• 14:58:05 - the aircraft initiated takeoff from the runway 15 of SBCA, with 58 passengers and 04 crew on board;

• - the PROPELLER ANTI-ICING 1 and 2 were turned on;

• 15:14:56 - the Electronic Ice Detector connected to the Centralized Crew Alert System (CCAS) emitted an alert signal upon passing FL130;

• - the AIRFRAME DE-ICING was turned on;

• 15:15:42 - a single chime was heard in the cockpit. Subsequently, the crew commented on the occurrence of an AIRFRAME DE-ICING Fault, and that they would turn it Off;

• 151549 - the AIRFRAME DE-ICING was turned off,

- the Electronic Ice Detector ceased emitting the alert signal.

• 1516125

• 1517:08

- the Electronic Ice Detector emitted an alert signal.

- the Electronic Ice Detector stopped emitting the alert signal;

- the Electronic Ice Detector emitted an alert signal;

- the Electronic Ice Detector stopped emitting the alert signal.

- the Electronic Ice Detector emitted an alert signal;

- the Electronic Ice Detector stopped emitting the alert signal;

- the Electronic Ice Detector emitted an alert signal;

- the SIC (pilot Second in Command) made radio contact with the airline's operational dispatcher at

Guarulhos airport, for coordination of the aircraft arrival;

• - At the same time of the SIC's coordination with the operational dispatcher, a flight attendant called

over the intercom. The SIC asked her to hold on moment and continued speaking with the dispatcher,

• - the Electronic Ice Detector stopped emitting the alert signal. At this time, the SIC was asking the

flight attendant for information that would be passed to the operational dispatcher;

• 16:17:32 - the Electronic Ice Detector emitted an alert signal; at this time, the PIC was informing the passengers about the SBGR local conditions and estimated time of landing,

• 16:17:41- the AIRFRAME DE-ICING was turned on;

• 16:18:41 - at a speed of 191 kt., the CRUISE SPEED LOW alert was triggered. Concomitantly, the SIC was about to finish relaying some information to the operational dispatcher;

• 16:18:47 - the PIC started the briefing relative to the approach for landing in SBGR. Concomitantly, APP-SP made a radio call, and instructed him to change to frequency 123.25MHz;

• 16:18:55 — a single chime was heard in the cockpit. At this time, the communication with APP-SP was taking place;

• - the AIRFRAME DE-ICING was turned off;

• 16:19:16 - the crew made a call to APP-SP (Sao Paulo Approach Control) on the frequency 123.25 MHz;

• 16:19:19 - APP-SP requested the PS-VPB aircraft to maintain FL170 due to traffic;

• 16:19:23 - the crew replied to APP-SP that they would maintain flight level and that they were at the ideal point of descent, waiting for clearance;

• 16:19:28 - at a speed of 184 kt., the DEGRADED PERFORMANCE alert was triggered, together with a single chime. The alert was triggered concomitantly with the exchange of messages between APP-SP and the Crew;

• - APP-SP acknowledged the message and requested the aircraft to wait for clearance;

• 16:19:31 - Passaredo 2283 aircraft reported receipt of the message and thanked ATC;

• - the PIC resumed delivering the approach briefing;

• - the Second in Command (SIC) commented, "a lot of icing";

• - the AIRFRAME DE-ICING was turned on for the third time;

• - APP-SP cleared the aircraft to fly direct to SANPA position, maintaining FL170, and informed that the descent would be authorized in two minutes;



• 16:20:39 - the crew acknowledged the flight instruction received (last communication performed by the flight crew);

• - the aircraft started a right turn in order to fly to SANPA position.

• 16:20:57 — during the turn, at a speed of 169 the INCREASE SPEED alert was triggered, in conjunction with a single chime. Immediately afterwards, vibration noise was heard in the aircraft, simultaneously with the activation of the stall alert;

• 16:21:09 - control of the aircraft was lost, and it entered an abnormal flight attitude until colliding with the ground. The aircraft rolled to the left to a bank-angle of 52 degrees, and then rolled to the right to a bank- angle of 94 degrees, performing a 180-degree turn in a clockwise direction. Subsequently, the turn was reversed to an anticlockwise direction, with the aircraft completing five full rotations in a flat spin before crashing into the ground.


Click on image to see it isolated




The ICING light would blink with the detection of an Icing condition and the Anti-Icing and/or De-lcing  (AIFRAME) were not selected to ON, followed by single chime. The light would remain illuminated in a continuous fashion with the systems turned on.

 

Anti-Icing and De-Icing Systems

 

The Anti-lcing functions were energized electrically, whereas the De-icing ones were provided by means of pneumatic pressure.

 

The APM system needed to be checked by the crew on a daily basis, and in case of a failure, an amber-colored FAULT message would illuminate on the APM panel.

If the aircraft's drag increased due to ice accumulation and performance was degraded, resulting in loss of cruise speed, alerts in three levels were triggered and presented to the pilots on both alert panels Of the APM, as follows:

• 1st Level - CRUISE SPEED LOW

The blue-colored message would indicate performance degradation Of around 10%, with reduction Of the Indicated Air Speed (IAS) during the cruise phase by at least 10 kt. below the speed computed by the APM.

This alert would be triggered only during the cruise phase.

• 2nd Level - DEGRADED PERFORMANCE

The amber-colored message would be followed by a single chime and a master caution alert, indicating a significant performance degradation in the range between 22% and 28%, induced by a significant increase in aerodynamic drag, causing a drop in cruise IAS of around 15 to 20 knots below the speed computed by the APM. This alert could be triggered during climb, cruise, Or descent.

• 3rd Level - INCREASE SPEED.

The amber-colored message would appear flashing, followed by a single chime and a master caution alert, indicating that the degraded performance condition had worsened , reaching an IAS value below the ICING BUG + 10 kt. This alert could be triggered during climb, cruise, or descent.

 


The pilot has set the ICING BUG SPEED for SEVERE ICING CONDITION to 165 Knots.


In addition to the speed alerts (emitted by the APM), the airspeed indicators of the left- and right-hand cockpit stations had BUGS for reference, particularly for minimum speed maneuvers at low bank, flaps O', and icing conditions (VMLBO ICING), The said BUGS could be adjusted manually.

 

The ICING BUG needed to be adjusted by the pilots for each flight in accordance with the aircraft's weight, in order to indicate the minimum speed for a flight in icing conditions and with flaps retracted. The VMLBO ICING.




















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