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.

AVIATION ACCIDENT ACCORDING TO A SINGLE CAUSE - The Main Cause

 

 AVIATION ACCIDENT INVESTIGATION 

Sources:

School of Public and Environmental Affairs, Indiana University, MT, USA

Clinton V. Oster Jr.

 

Mason School of Business, College of William and Mary, Williamsburg, VA, USA

John S. Strong

 

School of Public and Environmental Affairs, Indiana University, 1315 E. Tenth St., Bloomington, IN, USA

C. Kurt Zorn

 

A LEGAL APPROACH

Classify each aviation accident according to a SINGLE CAUSE after you having dissected the event chain of failures.

 

There have been decades of the misused term, LOSS OF CONTROL (in flight), to describe many written real causes of aviation accidents in the Final Investigation Report, since such term it overcharges the Pilot's onus and, legally prejudices the flight deck crew.

 

It's because categorizing every accident into a SINGLE CAUSE (the first event of the chain) is now an absolute requirement (Judicially). The investigators have responsibility to find 'what was the "atomic particle" of influencing the LOSS OF CONTROL, not only writing a generalized "accusation" without determining the first cause in the events chain, which it promoted to end up in the accident.

Widespread "prosecution" of pilots is illegal as using the term LOSS OF CONTROL without the determination of the first event that started the events chain for resulting the LOSS OF CONTROL. Those investigated aviation accident concluded as LOSS OF CONTROL they could have occurred for another main cause, such as maintenance failure, engineering design, mechanical failure, or a running software routine error.

If the Final Aviation Accident Investigation Report does NOT specify the first event that caused the result, the Report must NOT synthetize the cause as LOSS OF CONTROL.  

 

“Protected Disclosure”

Protected Disclosure means any good faith communication that discloses

• suspected improper governmental activity (IGA), or

• any significant threat to public/employee health or safety

 

PORTUGUÊS

"Divulgação Protegida"

Divulgação Protegida significa qualquer comunicação de boa-fé

que revela

• atividade suspeita imprópria do governo (IGA), ou

• qualquer ameaça significativa à  saúde ou segurança pública/funcionário

 

 

Purpose of the Written Report

• To evidence a timely and impartial institutional response

• To accurately document the investigation conducted

• To provide decision-maker with facts needed to decide the matter

• To ensure a successful investigation

• To best defend the investigation

 

The TOP-SET headings:

T ime, Sequence and History

O rganisation / Control / Responsibility

P eople and their involvement

S imilar events

E nvironment and its effects

T echnology, equipment & processes

 

Loss of lives it isn’t to be summarized on a mere wide-ranging technical aviation term, like LOSS OF CONTROL. That’s vague statement.

 

Even vague suggestion of Criminal Conduct may be defamatory Per Se.

 

Vagueness refers to a lack of clarity in meaning. For example, “Go down the road a ways and then turn right” is vague because “a ways” does not precisely explain how far one should go down the road.

 

Ambiguity is when there is more than one clear meaning, and it is difficult to choose which meaning was intended. For example, “Paul went to the bank” is ambiguous because bank could mean a river bank or a financial institution. “He was cut” could mean he was cut from the team or he was cut by a sharp object.

 

Another example: “The stool is in the garden” is ambiguous because stool could mean poop or chair.

 

PORTUGUÊS

A "acusação" generalizada aos pilotos é ilegal. O acidente poderia ter ocorrido por outra causa, como falha de manutenção, projeto de engenharia, falha mecânica e, erro de execução de rotina de software.

 

Houve décadas do termo mal utilizado, PERDA DO CONTROLE EM VOO, para descrever muitas causas reais escritas de acidentes aéreos no Relatório de Investigação Final, uma vez que tal termo sobrecarrega o ônus do Piloto e, legalmente, prejudica os membros da tripulação.   É porque categorizar cada acidente em uma ÚNICA CAUSA (o primeiro evento) é agora um requisito absoluto.

 

QUESTIONS ON REPORT TO BE ASWERED

- Who was involved in the accident?

- What actually happened?

- When it happened?

- Where it happened? And

- Why did the first failure event take place?

 

 

 Accidents are usually the culmination of a sequence of events, mistakes, and failures.

 

When planes crash, we want to know what happened. The good news is that there’s technology available today that it would give us the answers. The bad news is that the Federal Aviation Administration (FAA) has not mandated that aircraft operators install it [the tech], citing privacy, security, cost, and other concerns.

 

Commercial airliners are required to have only flight data recorders and cockpit voice recorders, commonly called “black boxes”, but the NTSB has long called for cockpit image recorders, as well. Such video would have been extremely helpful in determining flight crew actions in recent crashes in Texas, Indonesia, and Ethiopia.

 

Part 121 regulations or under Part 135 regulations.

Airline passenger service in aircraft with more than 30 seats has always been provided under Part 121 regulations. Traditionally, scheduled commuter service with aircraft with fewer than 30 seats and on-demand air taxi service has been provided under Part 135 regulations.

 

The goal of the analysis

 

Not all accidents are investigated by organizations with the resources or technical expertise of the National Transportation Safety Board in the United States, the Air Accidents Investigations Branch in the United Kingdom, the Bureau of Enquiry and Analysis for Civil Aviation Safety in France.

 

For example, an engine failure during takeoff where the crew fails to take the needed actions to land the plane safely with the result of an accident.

 

If more information is available for accidents in some sectors of aviation than others or in some countries than others, then there may be a tendency to find more errors in accidents where more information is available which could result in giving those accidents more weight in aggregate statistics.

 

The analysis of the example above should consider both the engine failure and the improper crew response as causes.

 

Approach to classify each accident according to a SINGLE CAUSE

 

An advantage of this simplification is that it is possible to compare a much broader range of accidents.

 

There are two basic approaches to assigning a cause or causes to an accident.

 

FIRST - Why did the engine fail?

SINGLE: Engine failure would be identified as the cause of the accident.

The absence of the factor that initiated the chain of events resulting in an accident, the accident could have been avoided.

 

SECOND - Why didn't the crew respond properly?

SINGLE: The cause of the factor that initiated the sequence of events that culminated in the accident.

I've called it "the atomic particle of influencing crew error".

That is an “unforced” pilot error rather than a failure to respond properly to an emergency.

 

One approach would be to assign the cause that was the last point at which the accident could be prevented. Pilot error would be indicated as the cause of the accident provided in the example above.

 

An example of the approach of assigning multiple causes to an accident is the Human Factors Analysis and Classification System (HFACS) developed originally for the Department of Defense and more recently applied to civilian aviation accidents (Shappell & Wiegmann, 2000).

 

HFACS has focused on aircrew behavior but could also be applied to human factors in maintenance, air traffic management, cabin crew, and ground crew.

 

In a re-examination of the link between an airline’s profitability and its safety record, Madsen (2011, p. 3) suggests that the “strikingly inconsistent results” in the existing empirical literature are due to an inflection point in the relationship between profitability and safety. His analysis “demonstrates that safety fluctuates with profitability relative to aspirations, such that accidents and incidents are most likely to be experienced by organizations performing near their profitability targets” (Madsen, 2011, p. 23).

 

If an airline is slightly below its profitability target, it has an incentive to increase its risk of accidents by spending less on safety. Or, if it is slightly above its target, a reduction in spending on safety can have a significant effect on its ability to remain above the profitability target. Conversely, when an airline is substantially above or below its profitability target, the incentive to reduce spending on safety is considerably less.

 

Investigating the link between maintenance and aviation safety

Marais and Robichaud (2012) look at the effect that maintenance has on aviation passenger risk. They found a small but significant impact of improper or inadequate maintenance on accident risk.

 

The effect that aging aircraft may have on accidents and overall safety levels

 

In an investigation of the effect the adoption of strict product liability standards has had on the general aviation industry, it was found that liability insurance costs for new planes increased significantly (Nelson & Drews, 2008).

 

The concept of latent and active failure and considers four levels of failure:

1) unsafe acts

2) preconditions for unsafe acts

3) unsafe supervision

4) organizational influences

 

Individual error categories within each causal category (Wiegmann et al., 2005)

 

In one study of human error in commercial aviation accidents, the results were reported aggregated into 18 causal categories (Shappell et al., 2004). Not all accidents were included in the analysis, only those where there was some error by the aircrew. The results were reported as the number of accidents in the data set that were associated with one or more of the error categories that make up each causal category.

 

Part 135 air carriers operate smaller aircraft in both scheduled (often referred to as commuter) and nonscheduled (often referred to as on-demand) service typically into and out of smaller airports than those served by Part 121 air carriers.

 

Within the Part 135 industry, the distribution of accident causes for scheduled and nonscheduled services are very similar, so they are not presented. However, the distributions of causes for Part 135 accidents in Alaska services are noticeably different than for service outside of Alaska.

 

For Part 135 service in Alaska, pilot error is even more prominent, accounting for 83 percent of both accidents and fatalities. The reasons for these differences are also not understood.

 

The Swiss cheese theory

The “ Swiss cheese effect ,” also known as the “cumulative act effect,” comes from the work of James Reason, a British psychologist who analyzed systemic failure in terms of four levels of human error:

1. Unsafe supervision

2. Preconditions for unsafe acts

3. The unsafe acts themselves

4. Organizational influences.

 

 

The Swiss cheese model of accident causation

The Swiss cheese model of accident causation illustrates that, although many layers of defense lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur.

 

The Swiss cheese model of safety

The theory is that the multiple layers of cheese represent a process safety system. If several slices of cheese are stacked on top of each other, the hypothesis is that the holes would not align, which would shield the beam of light, preventing a hazard from passing through the layers (and resulting in catastrophe).

 

Human error theory

With human error theory, a violation occurs when an individual deliberately and knowingly chooses not to follow a guideline or rule. These latter types of error are cognitive failures and are either due to actions not going as planned (slips/lapses) or plans being inadequate to achieve the objective (mistakes).