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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