Critical Aviation Safety Issues Emerge from Voepass ATR72 Accident - Episode 238
Вставка
- Опубліковано 10 жов 2024
- The preliminary accident report on the August 9, 2024 crash of a Voepass ATR72 near Sao Paolo, Brazil has just been issued. John Goglia, Todd Curtis and Greg Feith apply their expertise to examine the findings and critical aviation safety issues.
The report has detailed facts, including a summary of the flight, but several key pieces of information are missing. One big issue - no detailed transcript of what was said in the cockpit during the flight.
The report focuses on the aircraft's deicing and anti-icing systems, including its apparent malfunctions. This system was first activated after the crew received an alert from the aircraft's ice detection system, and was turned off less than a minute later.
The crew did not react appropriately after turning off the deicing system warning. Rather than leaving the altitude where the icing was occurring or disengaging the autopilot, the crew did neither.
Based on the portions of the crew's conversation during the flight in the report, John concludes that the crew was not paying enough attention to flying the airplane. They did not address warnings from the aircraft.
There is a potential conflict of interest that may impede getting all the details of this accident. The Brazilian Air Force runs CENIPA, the aviation accident investigative authority, and the Brazilian air traffic control organization. Greg and John share their firsthand experiences with investigators dealing with outside influences using the example of the 1994 Roselawn, Indiana ATR72 accident.
Key takeaway here: pilots, especially professional pilots, need to educate themselves about how icing affects their aircraft.
Related documents are available at the Flight Safety Detectives website.
Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives UA-cam channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.
Music: “Inspirational Sports” license ASLC-22B89B29-052322DDB8
Better late than never.
I’ve been eagerly awaiting the FSD’s take on this preliminary report, and good to see Gregg back on board.
Fly with Magnar (a channel run by a Type Licensed Instructor on the ATR 72 for the ATR community) somehow got a few more bits of information on this...
he does it far more technically and in depth. but here is my summary as I understood it:
1. they took off with a known bleed air valve failure, allowing bleed air only from one engine to power the systems requiring thesame... this was passed on to the Pilots at the last minute, and meant they had to follow quite a few performance limitations, including flying no higher than 17'000 feet, which is the level they chose for the flight (i.e.: no margin for error should performance decrease further)
this failure also meant a serious thrust deferential on the two engines... between 8%-14% depending on exact conditions, this was combated by staggering the thrust leavers, however, when the stall recovery maneuver moved both levers to full power this suddenly gave a very strong yaw input right as they started to stall... probably dooming the flight
2. the specific failure in the de-icing system was an overheat, for which the crew likely used an unofficial but common procedure attempting to cycle the system however, as it required input from both pilots, (one of the reasons why this isn't an approved method) they became tunnel focused on it to the detriment of monitoring the issue developing... just a theory, but based on something he had seen before.
the last shut down was automatic, and they did not react to it at all for a time.
3. one of the warnings they were getting was based on a system neither pilot likely actually properly understood, most airlines teach this system as being auxiliary and not to be relied on for normal flight. it was also not part of the QRH.
He points out that INCREASE SPEED is a memory item emergency procedure. Push the nose down, gain airspeed. Do not ask ATC. Do not think. Push the nose down immediately. That warning means you screwed up some time ago and let things get very bad.
He questioned whether the company training was sufficient on covering this and other aspects. If the pilots had pushed the nose down at that moment it would have been fine.
Secondarily: the issue was not bleed air, it was one of the AC Packs. The de-icing system taps bleed air prior to the pack so the de-ice fault shouldn't have been related. The 17,000ft limitation in the MEL is due to lack of redundancy of the pressurization system with one pack inop.
@@xenadu02 In the AERO Caribbean Flight 883 ATR-72 accident due several icing (2010), after the stall the plane have nose down, and for briefly moments reach 200 knots, but was not recovered.
Anyway in the TRIP Linhas Aéreas AT%-72 serious incident due icing (2013), despite pilots wrong actions* - PIC fight the stick pusher, and SIC feathered the propellers, the aircraft levered at FL 110 after fall ~5000 feet and are able to land safety in destination.
* Or perhaps due these wrong actions - against what the aircraft manual instruct.
What I've heard is that the 17,000 ft altitude restriction seems like it wouldn't normally affect planning. Since due to the weight and distance, even without that restriction it wouldn't have the performance to fly much higher.
That´s indeed a very good hint.🙂👍 I can only support it to watch Magnar´s videos about this crash. Also take a look into Juan Brownes = Blancolirio´s debrief. He´s not going so much into technical details as Magnar but he is very educational.
@@xenadu02 Indeed, exactly.
The collective wisdom and insight here as always amazing. Thank you.
As a former Brazilian air traffic controller and ATR pilot, I'm glad that you mentioned the possible conflict of interest between the investigation and the Brazilian Air Force, as it really happened in the GOL/Legacy Mid-Air Collision. The ATC software (X-4000) had some serious built-in failures that led to that midair collision. It's important to note that CENIPA started their presentation mostly defending the fact that, since the pilots did not declare "MAYDAY," the ATC could not have provided any assistance. A true civil and independent Investigation Agency should be created in Brazil.
Parabéns.
The only conflict of interest I see in past CENIPA reports, which have been just as thorough as a NTSB report, is that the Legacy collision report attributes the transponder being turned off to a random failure even though no such failure has ever occurred nor was able to be replicated after the extensive testing that's reported in the CENIPA report.
It would, of course, be politically untenable to suggest the US pilots were carrying out activities that would require turning off the transponder (because God forbid the US does something reprehensible in Latin America, am I right), so the issue was considered closed and everyone just reports this as a random transponder failure.
"After the execution of all the tests on the N600XL airplane, as well as the bench and integration tests of the units, no factual evidence was found that could explain the discontinuance of the transponder signal transmission, in terms of failure or abnormal behavior of the N600XL systems. The technical history of the N600XL aircraft did not show any evidence associated with failures or abnormal behavior of the Transponder and TCAS systems. All the documentation pertinent to theses systems was verified, and no indications of non-conformity were found relative to the systems investigated."
@@DrVictorVasconcelos exactly that: “that you see in past CENIPA reports”. It doesn’t even mentioned the fact that X-400 ATC Software has a LOT of bug, glitches and unsolved miss behaviors that led to the crash!!!
Thank-you - this was a nice complement to Magnar's quite comprehensive pilot's view of the situation these people found themselves in ( he declined to speculate at all, but he did go into a detailed breakdown of the aircraft systems, and the flight timeline ). I believe there'd been multiple reports of severe icing in the general area before the flight too. I'm not really a pilot ( I know how to fly, it's not the same thing ), but I got quite a way into the further education needed for a career in technical aerospace before switching track & kept up with it over the years, so I can at least appreciate what was going on here, and I've got to agree there seemed to be a certain lack of appreciation of the facts going on up there...
Well, let's see how the final report reads, that'll also say a fair bit about the authorities involved. Will appreciate your take on that one too.
Update to my prior comment: Thanks for including your dissertation with the episode docs. I'm reading through it now. I'd love to hear more discussion about some of the specific clashes the NTSB and FAA have gotten into, as well as for someone to explain the controversy over Mary Schiavo after ValuJet 592 and TWA 800. I've seen her referred to as "Scary Mary" by some in the industry, but I don't know much about what their actual criticisms are.
Thanks for taking the time to read my dissertation. It was a fascinating intellectual journey that took me well beyond my engineering and statistical focus. My dissertation was not the first in-depth look at the politics of aviation safety, and it won't be the last. It is a complex and evolving subject. One thing that radically changed starting in the 1990s is the aviation community and the general public's ability to access far more information about what aviation investigation organizations worldwide do. The NTSB is perhaps the organization that has more public access to its inner workings than any other national investigation organization, but access alone is not enough to enhance the quality of their investigations. In my opinion, it is up to the public, both aviation insiders and the general public, to take the actions needed to ensure that the NTSB continues to improve.
Thank y'all for sharing your knowledge and experience! As a Brazilian, I feel honored and grateful for helping to clarify what happened. The airline is from my hometown, and is the oldest company in Brazil still in operation.
With the problems the ATR has had with icing over the years hard to believe they stayed in Icing conditions even with a Deicing Fault. Check list is very specific you have to get out of the icing conditions. Reduce altitude by 3-4000 feet they would of been clear of icing conditions. We thought after our accident in 1994 everything was done to make the ATR the safest Turbo Props to fly in icing conditions. We have been proven WRONG once again.
The root cause Is INTACT
The collective institutional context on y’all’s site is invaluable.
You guys are legends and as a future pilot I greatly appreciate everything you guys have done and continue to do to enhance safety in the industry
Hiya Greg. Nice to see you again. 😊
Given the history of the ATR 72 / 42 trouble with Icing, one would think the cockpit crew would have been"freaked" out with the icing reports and the degrated performance alerts... Why they wern't on edge and so complacent to heed the controllers directives and NOT take action to avoid the icing..Needs to be studied.
Similarly to Aero Caribbean Flight 883 accident (2010), in this despite recognize the ice problem and activate the de-icing system the pilots ask ATC for descent, but don't react for the airspeed decreasing, awaiting ATC instructions, when this came and they start a right turn the plane was at 157 Knots, stall and don't recover.
Waaaa greg. I Just know you usually from Air Crash Investigation. Glad to know you on other platform
Ice has been dropping these style of planes for years 🫣
Thanks, gentlemen. Really enjoyed that. 53 minutes flew by, lots of insightful thoughts. Definitely want to see more of your vids.
Thank you for your information and time here it was very interesting. As a "COM AV" guy, it always intrigues me on the work that you guys do to bring out the outcome of what has happened. The Video of this accident was horrifying and that there was nothing they could do once in that attitude.
Pilot Blog is a channel of a (former) ATR-72 pilot and did a video shortly after the crash. The sister of First Officer Jeff Gagliano (who was the pilot flying AE 4184 in the Roselawn crash) commented on that video and now learning details from the preliminary report.....her comment is even more heartbreaking. I won't copy/paste the entire comment, but the last sentence of her comment: "It will be 30 years ago in October and the memories of the crash never goes away."
This prelim report and seeing how they dismissed multiple warnings multiple times.....very frustrating. My heart goes out to the family and friends of all who died..... both in the Voepass and AE 4184. And to @cindygagliano5319 - on the off-chance you read this, sending healing energy to you and your family.
Todd, I would be curious to read your dissertation. Would you be willing to post it with the other episode documents on the website?
Very insightful analysis, thank you.
I’ve listened to airplane disaster for years and these three guys were great. They have aged as I. Glad to hear from these smart men !
I had a crush on Greg when I was in my teens
If only I could go back to my teens and watched this cutie, my crush 'o meter would've went sky high. ❤
Pilot training 101 - No auto pilot when in icing, suspected icing, or icing is likely.
RIP.
As a former airline pilot, and current instructor
...I would fly in the back of any ATR ----given the pilots where trained by a good airline.
I'm not familiar with Voepass, or their training or icing procedures
...So, no judgement on Voepass.
This could be one isolated case of pilots not following company and/or ATR procedures.
Great show
It was also known in the report that one of the air conditioner packs was out of service. According to the MEL or minimum equipment list, they are restricted to 17,000 feet while this pack was in operative.
What I've heard is that the 17,000 ft altitude restriction seems like it wouldn't normally affect planning. Since due to the weight and distance, even without that restriction it wouldn't have the performance to fly much higher.
Indeed. And that meaned that they stuck right in the middle of the severe-icing-zone during their whole cruise flight.
Check the typical cruising altitude of ATR72s in FR24. Most will be flying around FL170 anyway.
@@coriscotupi In Brazil: yes. Whyever. In Europe 24000 feet is the usual altitude of ATR. Their maximum altitude is 25000 feet.
@@NicolaW72 As I speak, I seer 41 ATR 72 aircraft flying over Europe in Flight Radar 24. Of those, 3 (three) are at FL 200 or above. The vast majority is well below. You may want to check.
"Increase Speed" light on with 169 KT, aircraft contaminated by ice, turn with a bank of 32 degrees, increased load factor, increased stall speed, those are the recipe of the tragedy.
love youre program 5*****
I remember rose lawn I was a reporter at a Major tv news station in Chicago and I covered that story…
These gentlemen are from a time when the federal government wasn’t an f-ing joke like it is today. How times have changed, we used to have public servants who were professional and dedicated public safety and doing the right thing.
During my years in aviation, both inside and outside of government, I was often at a loss to explain how these highly complex technologies and processes worked as well as they did, and continue to do. People and organizations are often imperfect, but the collective desire to keep pushing forward is the secret sauce. Every era has to figure it out for themselves, and I will continue to do my tiny bit to help current and future aviation professionals to move aviation forward.
What would have been the first best flight-crew actions (apart from refusing to take off into known icing conditions, with the known defect)? Should they have reduced altitude and turned back at the first de-icing fault alert?
Task saturated pilots losing focus. Never forget, it’s *Aviate Navigate Communicate*
They focus in the Communicate part and leave the Aviate Navigate with auto-pilot.
@@Sokol10 exactly
Because of this dangerous icing I would not fly in it.
I heard that the wing section/crossection shape was such that ice gathered quickly at the rear of the wing just ahead of the ailerons so making the aircraft uncontrollable. There was a flight test that showed this formation of ice after the the Chicago accident. Because of cost this will be difficult to make it safer. I think the NTSB makes recommendations but it’s up to the FAA to decide what to do. Maybe they might decide to fly on accepting a fatal every few years. Just blame the pilot . There is no problem like this with DHC8-400 which I have flown in often. Luckily there are very few ATRs in Canada. It will be interesting to see the final decision about this accident in Brazil.
Please, WHICH magazine are you talking about, Guys? How can I have access to that? Kindly
I’m a retired certification and have tried to follow this up as I think these aircraft are unsafe e in icing and have had a few fatal accidents As far as I have found outyheahape of the wing section allows ice to form neartheailerons andcauseloss of control of course they blame on the pilot BUT it’s thewingsection used on the wing Aircraftmustbegrowded
Do you read all of the comments?
This episode seems to have an ad every 3 minutes. Hard to listen to.
get an ad-blocker, best creation ever.
It is a more than a bit annoying, and I'm too cheap to pay for ad-free UA-cam access. When it gets too annoying, I'll open up my wallet.
There is a plan to fly a Citation Bravo from Malaysia westward through Greenland n Iceland to Anchorage to Canada n finally to California within the next 2 months. I am very concern. Can someone share some advice to me?
There is no mystery that these ATR turboprops are thoroughly under engineered. They should only be flown in the fairest conditions. There's something about the angle of the wings relative to the direction of travel that I find very unsettling. If the wings were a little bit swept back, like an arrow, and given a little bit more surface area to compensate, then I don't think this icing problem would be as big of a deal as it is. The trouble is that ice builds up all at once along the entire leading edge. When it reaches a certain threshold, all of the lift generated by the wings disappears with no warning. Because of that cutting angle, you've either got lift or you don't have any lift. There's no in between state -- no warning -- no chance for a pilot to respond. Flying an ATR is like balancing a pencil on a thread.
My thoughts too , don’t like that wing .
As a flying ATP and an ex R&D engineer in aeronautics (structure, aerodynamics and jet engines) and airspace technologies (mostly engines) seeing somebody writing“There is no mystery that these ATR turboprops are thoroughly under engineered” is TOTALLY erroneous and shows a TOTAL lack of knowledge and experience!
After the grounding of the ATR for more than a year about 30 years ago and its new modifications, this airframe went into the most strenuous icing tests, above the limits of previous icing certification at the demand of the French and ATR, that even the FAA didn’t want to go that far, but finally accepted to increase the limits of icing certification. After these extreme tests, including in flight with a US airplane throwing cold water in cold conditions, the new systems and modifications passed those tests that no other same type of airplanes build at that time could go through and even most aircraft builders abandoned building these type of airplanes… only the Bombardier Dash 8 Q400 survived these tests. So, saying “these ATR turboprops are thoroughly under engineered” is showing your total ignorance in this technical field… and a TOTAL lie through your ignorance.
As a professional pilot, now, flying jets, you don’t want to ever stay in icing conditions, even with de-ice systems, ESPECIALLY when you encounter extreme icing, like supercooled water droplets. One of the advantage that jets have when encountering icing, compare to these types of turboprops which are limited to a MAXIMUM of 25,000 ft (with no passengers), is to climb above the weather. When we have to descend, we (professional pilots), do not want to stay longer than even 3 to 5 minutes (and this is even too long for conscious safety and serious flying). I have been in these conditions with moderate/severe turbulence (autopilot disengaged) and moderate to severe icing (and luckily for us that was “just” rim ice, not clear ice which is one of the worst icing you can encounter), and I wish I wouldn’t ever had to fly within it, but this lasted “only” for about 1 minutes as the approach controller was giving us instructions in a busy terminal area. Those are rare occurrences as good controllers generally try to make us circumvent these conditions, but sometimes there is no other way and they expect these conditions will not last long.
If you had really listen to these knowledgeable gentlemen in this video, you will not have wrote down this nonsense and bashing this great and useful airplane. Pilots in this ATR were not up to the level required to be safe professional pilots and put the plane in these conditions, not the way around, especially with this MEL limitation they had.
Learn AND listen before making “POVs”, because otherwise it will show your ignorance… and in this case it is flagrant!
@@Speedbird61 3 planes crashed during that day. August 9th 2024: Chile, Brazil, Argentina, in a span of 6 hours.
The plane's poorly designed and must be removed. Besides, it entered a flat spin. You don't enter a flat spin on the A320 by having SIGMET + autopilot. On top of that, another fellow FO (of an A320), warned minutes before the icing conditions to ATC. He basically undergo the same problems, but was able to recover, and landed safely.
Source:
'Un piloto de otro avión pudo evitar la tragedia en Brasil pero la torre de control lo ignoró: “Nunca vi algo así”'
The plane tried to save them.but
You know AA was bad enough when they were on their own but since the merge with U.S.AIRWAYS they got worse it’s bcs USAIRWAYS ironically had the upper hand in the merge they only kept the AMERICAN name bcs it’s bigger who ur really flying is USAIRWAYS…
As a landlubber, i wonder if on any flight there will be a capt sullenberger behind the yoke or a ding bat like on this Brazilean flight, the passengers have no way of knowing.
After decades around aviation safety and a few hundred hours of personal experience as a pilot or crew member, my opinion is that is is hard to predict if a crew member will be a Sullenberger, a dingbat, or something in between when a truly life-threatening emergency arises.
@@airsafe Exactly and that is the weak link in aviation. An appropriate analogy is a super talented boxer who is fed a stream of sub- par opponents so he looks unbeatable, knocking them out and everyone says hes the second coming of muhammad ali but then some nobody pug refuses to submit and breaks the will of the so-called phenomenon and makes him quit on his stool in a cowardly fashion. Everyone is a frontrunner until they face real adversity.
Before you tunnel vision on the Brazilian crash, I re ember decades ago, there was a similar? crash in US, an ATR just dived into the ground. They suspected ice on the wings , ahead of the ailerons, the French were recommended to redesign the wings but they deny all faults. Maybe you should dig up that report before you make any comments, just as they dig up previous 737 Max crashes.
That's the Roselawn crash, and they discuss the NTSB report and their disagreements with the BEA extensively in this episode. Did you listen to it?
I believe you are referring to the crash in Roselawn, IN in 1994. The episode's page at flightsafetydetectives.com/critical-aviation-safety-issues-emerge-from-voepass-atr72-accident-episode-238/, and you can download the French BEA response at flightsafetydetectives.com/wp-content/uploads/2024/09/NTSB_Roselawn_IN_AAR9602_Rebuttal_Report.pdf
Just like the max pilots bunch of clowns.
A los of flaws in this aircraft. Not only ICE
Greg Feith was LITERALLY THE NTSB INVESTIGATOR IN CHARGE of that ATR accident in 1994. Try to keep up FFS. Maybe *you* should dig up some basic facts before *you* make any comments?!
Robotic behavior.
1/. Why and how do ATC and the pilots get into a severe icing situation in the first place, and then stay there? If it's a surprise - which can't be here because of the constant warnings - then why aren't they changing altitude rapidly? ATC eventually said stay at 17,000 due to traffic, but that's where the icing was and it's up to the pilots to fly the thing safely. Would speeding up the aircraft 40kts saved it?
2/. Yet again we see (alleged) pilot inexperience and lack of quality as a major culprit. Together with blase', bored and disinterested attitudes when flying everyday sectors. Obviously it doesn't 'necessarily' matter the modernity of the aircraft, what matters who is up-front flying it. Lesser brands pay less and hire less. Are cheaper ticket prices worth your life?
Guys we can do without the political stuff (we all know how reality works).
We don’t need to be EINSTEIN to know how many mistakes….. The problem is what you can’t see. The high cockpit temperature played a role? Airplane externally freezing but internally burning. I don’t trust in ATR guys and today investigators too. PILOT ERROR is the easy way. I hope investigators publishes everything like controls position and forces applied for example. The big problem is if findings imply spend a lot of money fixing things………
The FVR of this aircraft don't record controls positions and forces applied, plus other parameters, authorized by ANAC - Agência Nacional de Aviação Civil (National Civil Aviation Agency of Brazil) due a fault system, neither the CVR records will be released to the public, as it has been prohibited by Brazilian legislators.
@@Sokol10 Thanks. Very convenient and in line with hidden politics.
Just like the max crash pilots, a bunch of clowns.
The top 1% doesn't care about our safety or what we think of them. So our safety heroes expose them everytime.
Seems quite counter-intuitive to have the autopilot NOT disengage when icing is detected and no Icing avoidance action occurs: since the first point in the checklist is "leave and avoid" the aircraft software *should* flag this in some fashion, and, if the autopilot function has to implement corrections that would be typical of an icing condition.... Really, ATR is allowing the autopilot to fly the aircraft into an unrecoverable status.
Absolutely the pilots at fault for not following "the book", but the manufacturer has allowed the fatal situation to occur, by not implementing a "hard stop" condition when
autopilot is on
and ice detected
and no corrective action taken
And autopilot is forced to implement unusual trim/power
But, what do I know, them Brasilian aircraft manufacturers are supposed to be pretty smart.
Maybe Embraer is doing a better job on their very popular new
Military transport.
I understand that many aircraft have problems with the autopilot taking the plane to a certain limit without warning.
The autopilot informing what it is doing would certainly make aviation safer.
yes, it should provide some kind of warning that it's operating the aircraft at an unusual airspeed/power/AoA...
Pilot training 101 -
no auto pilot when in icing, or suspected icing.
International Civics Education of Sundays:
Context:
X account, same username.
No airline should be operating the ATR aircraft, except in tropical areas where there is no possibility of icing encounters. You can trust no one in their respective selling business. Lives do not matter, money is king.
The Brazilian crash happened in the tropics.
Airplanes go up into the air. The air cools as you head up. It doesn't matter where you are.
Stay off Silver Airways! They fly ONLY ATR 72's!!!!
Nothing wrong with an ATR, or any turbo-prop used by a modern airline.
Do not waste time talking BS, and get on with the message
Icing Conditions existed between 12,000 ft and 17,000 ft [ the maximum altitude this particular ATR72 was permitted to fly at due to one inoperative conditioned air / pressurization pack ] .. The air-conditioning / pressurization packs use hot bleed air from the two engines to provide interior cabin pressurization and cabin heat, and also feed the engine intake, wing and Horizontal Stab de-icing systems [ the expandable rubber boots that inflate to break the ice accumulation and throw it off ] ..
Dispatch with a single inoperative pack is acceptable as long as certain limitations are taken into account. Conditions for this particular Voepass aircraft included restricting its altitude to 17,000 ft. The Departure was CLEARED FOR TAKEOFF.
AT THE VERY MOMENT the "anti-ice / de-ice" FAULT LIGHT / WARNING HORN was detected, the crew was REQUIRED - BY THE FLIGHT MANUAL - to IMMEDIATELY EXIT Icing Conditions and descend below 12,000 ft [ the floor of the indicated icing conditions ] -- this they FAILED to do [ in direct violation of procedures clearly laid out in the FLIGHT MANUAL - in other words, communication to or from the Control Tower is 100% moot and completely unnecessary - the CREW has FULL IMMEDIATE AUTHORITY, as a result of an immediate threat to the Aircraft's Safety of Flight, to begin descending , and to TELL the Tower that they ARE DESCENDING - the Tower has ZERO Authority to over-rifde this decision.
A BREAKDOWN THE CENIPA FLIGHT SYNOPSIS :
After the ATR took off from Cascavel’s runway 15, propeller anti-icing was switched on.
As it climbed through 13,000ft -- [ 1,000 feet ABOVE the ICING FLOOR, btw ] -- an electronic ice-detector sounded, and the crew turned on the airframe de-icing system.
But, THEN, shortly afterwards, the crew remarked on an airframe de-icing fault and switched the system off.
AT THIS POINT THEY SHOULD HAVE IMMEDIATELY DESCENDED TO BELOW 12,000 FEET -- they question is: WHY DID THEY CONTINUE TO CLIMB whe the FLIGHT MANUAL clearly tells them they MUST EXIT ALL ICING CONDITIONS.
This act of incompetence IMMEDIATELY disqualifies these two pilots and they should have never passed their last flight exam.
Over the next hour of flight, the electronic ice-detector issued at least five alerts, each lasting several minutes -- but the airframe de-icing system was only turned on as the aircraft neared Sao Paulo and the crew was co-ordinating with the airline’s operations control at Guarulhos ..
About 1 minute later, the aircraft’s performance monitor - which checks for higher-than-expected drag from ice accumulation - warned that the CRUISE SPEED WAS LOW. The aircraft was traveling at 191 kts - which is already VERY LOW for an ATR 72, which has NORMAL cruise speed [ without icing conditions ] of abt 272 kts, and a MAXIMUM cruise speed of abt 299 kts ..
The NORMAL CRUISE Speed -- IN Icing Conditions -- is "PLUS 15 KTS" [ in this airplane's case, roughly 287 kts, depending on aircraft's weight at Take-Off ] -- Again, this CLEARLY NOTATED IN THE FLIGHT MANUAL and requires ZERO Communication with Flight Tower, except to communicate 'expected final approach time' for landing co-ordination and aircraft spacing ..
As the crew started briefing for the approach and contacted Sao Paulo approach control, the airframe de-icing was again turned off .. [ AGAIN -- WHY? - WHAT ARE THE ICING CONDITIONS AT THIS MOMENT - and remember they had a ICE FAULT Indication approx an hour earlier ] ..
Approach control instructed the aircraft to remain at its cruise altitude of 17,000ft owing to traffic congestion at 15,000ft from a Gol Boeing 737 and a LATAM Airbus A321 ..
WHY did the crew NEVER inform tower or approach control that they had experienced an ICE FAULT CONDITION and NEEDED to IMMEDIATLY DESCEND below 12,000 FT [ which SHOULD HAVE HAPPENED a FULL HOUR earlier - but didn't ] ..
The ATR THEN slowed to 184 kts and the performance monitor issued a higher-level alert, indicating a further degradation. This alert sounded as the crew was exchanging communications with air traffic control ..
Upper atmospheric data shows the air was “very humid” which, combined with the sub-zero air temperatures, “favored the occurrence of severe aircraft icing” between 12,000 ft and 23,000 ft [ the airplane being limited to 17,000 ft ] ..
As the aircraft continued to hold for clearance, the first officer remarked that there was “a lot of icing”, and the crew turned on the airframe de-icing system for the third time [ which should have NEVER been turned off in the first place - unless there was some sort of electrical fault - the kicking of circuit breakers occuring - which should have told them to immediately descend and head for the nearest airport ] ..
Controllers instructed the ATR to fly to the SANPA waypoint at 17,000 ft, advising the crew that descent clearance would follow in about 2 min - but, remember, in ICING CONDITIONS with an ICE FAULT or Performance Degradation Light, the CREW has IMMEDIATE AUTHORITY to DESCEND BELOW THE ATMOSPHERIC ICING WITHOUT asking for clearance from the tower ..
But the crew acknowledged this instruction, and the aircraft commenced a right turn towards SANPA.
After stalling, the aircraft descended in a flat spin before crashing into the grounds of a condominium.
But as it turned, with its speed having fallen to 169 kts, the aircraft began to vibrate, and a stall alert activated, along with a warning to increase speed.
The aircraft rolled 52° left, then 94° right and turned 180° clockwise [ a nose to tail swap ] ..
This turn then reversed to anti-clockwise and the ATR descended in a flat spin, fully rotating five times before striking the ground near Vinhedo.
None of the 58 passengers and four crew members survived.
CENIPA stresses that final conclusions have yet to be drawn over the accident, and several avenues of inquiry are being followed.
“It is important to emphasize that there is no single factor for an accident, but rather several contributing factors,” says investigator-in-charge, Lt Col Paulo Mendes Froes.
“In [ this case, ] loss of control of the aircraft occurred during the flight under conditions favorable to the formation of ice, but there was no declaration of emergency or report of adverse weather conditions.”
He points out that the aircraft was certified for flight in icing conditions and the crew had each logged over 5,000 hours. The inquiry states that the captain had 665 hours on type compared with over 3,500 hours for the first officer.
CENIPA says the investigation will pay “special attention” to the aircraft’s anti-icing, de-icing and stall-protection systems, while also examining human factors, operational aspects and technical conditions.
ATR has noted the publication of the inquiry’s preliminary findings, and says the manufacturer “reaffirms its full support” to the authorities involved.
RECOMMENDATION by Brad Hartliep, Independent [ NON NTSB ] Aircraft Crash Investigator , Aircraft Engineer , FAA A&P IA , STC Modification and Commercial Aircraft Flight Test Approval Process , FAA Regulations and Compliance Training Officer , FAA/CAA/JAA Maintenance Training Officer , Aircraft MRO Quality Assurance / Quality Control Inspector , and Pilot ..
37 years of Crash Investigation Experience - including "Roselawn" , "Ramstein 88" [ I was there and involved in the First Aid, Rescue, Recovery and Investigation ] , "Lockerbie" [ I was there post-crash - from Ramstein - and involved in the recovery ] , "Dallas B-17" [ I was there, and as a B-17 Crew Chief, Flight Engineer and A&P IA , was involved in the recovery and investigation ] , "Alamogordo F-15 Crash 1986" [ I was assigned to 5th FIS and involved in the Recovery and Investigation ] , three F16/GE F110 crashes in South Korea [ 87- 88 - I was there and involved in the recovery and investigation ] , and dozens of other research investigation global aircraft crashes from the 1950s "Grand Canyon" Crash to the Present ] :
ATR Flight Training MUST BE IMPROVED and actions to " LOWER THE NOSE, ADVANCE THROTTLE TO MAXIMUM CRUISE SPEEED, AND DESCEND BELOW ICING CONDITIONS " MUST OCCUR ON THE FIRST WARNING LIGHT [ increase speed - which should probably now be TIED to LIGHT THE SECOND WARNING LIGHT [ degraded performance ] at the same time ] and not the Third -- which is CLEARLY FAR TOO LATE in the warning system ..
This plane may not have taken off if the flight plan meant flying through severe icing as reported by SIGMET, per instruction manual. All the passengers needed to know was flight cancelled due to weather. Nonetheless, the crew threw caution to the wind, took off, dialled in FL and heading, and did nothing until it went south more than an hour later.
@@honeyflo88 This Aircraft was flying with one PACK inoperative, so according to MEL it could not fly higher than 17000 feet = it stuck the whole time at cruising altitude right in the middle of the severe-icing-zone. Under such weather conditions it shouldn´t have been dispatched to fly this route = clearly Airline fault. And that is only ONE point of a couple which indicates that it is a more complex story than "only" Pilot Error - allthough the Pilot Errors were serious and scary.
Thank you very much for your extensive work to summarize these crucial information about this crash here and to ask some important questions!🙂👍 The Pilot Errors are indeed shocking. But no mental sane Pilot would do them voluntarily. Reading this Preliminary Report gives you the feeling that the Pilots were at no point of the flight aware about the increasing danger. That it was not "only" a lack of situational awareness but a lack of knowledge or maybe a case of normalization of deviance. And this raises the question if it was solely their failure or if something seriously was wrong inside of this airline, with their procedures, their training, their safety management system. And then add to this that this particular aircraft with this MEL-restriction was dispatched by this airline onto this route in this weather conditions. It really reads to me like a more complex story.
Nevertheless: The Pilots failed in a disturbing way. They had simply to follow their checklist/s and everybody would have reached safely his or her destination. An additional question which I have is therefore: Used this crew at any point of this event their checklists? And if yes - when and how? Be able to answer this questions would probably mean to know more about what was really going on here.
What I've heard is that the 17,000 ft altitude restriction seems like it wouldn't normally affect planning. Since due to the weight and distance, even without that restriction it wouldn't have the performance to fly much higher.
@@NicolaW72 What I've heard is that the 17,000 ft altitude restriction seems like it wouldn't normally affect planning. Since due to the weight and distance, even without that restriction it wouldn't have the performance to fly much higher.
He had enough fuel to fly at 10,000 feet and change course to avoid bad weather if necessary. Many other flights in the region did not suffer the same fate.
We can always improve a system, but, in my opinion, there is a glaring piece of information missing in this analysis, which leads to a conclusion that will do little to prevent a recurrence.
In my opinion, it is wrong to suggest that if the aircraft had a better Ice Protection System (IPS) it could fly in severe icing. Until we make an aircraft with a fully heated exterior surface, it is not possible; I agree with the French manufacturer that there is no need to elaborate on how an aircraft might react when flying into situations in which it is not certified to fly. Would it help you to know how your car would be destroyed if you drove it into a rocky ravine? It better be a Tesla (‘Tesla plunges 250 feet off a California cliff, all 4 occupants survive’).
The same applies to flying into a thunderstorm: if you don’t know how to avoid a thunderstorm, I doubt that the knowledge of all the destructive forces acting on your aircraft would help you find your way out of it.
« In other words, can we expect a pilot to know how to exit severe icing conditions graciously if he does not know how he got there in the first place? »
Knowing that no aircraft is certified to fly in severe icing, the first « ordre du jour » would be to not enter severe icing. How? Avoid precipitations.
If the pilot enters precipitation in clouds, he will encounter situations that will challenge all the airmanship he has left and it may not end well, as we saw in these accidents.
"Really, the question is; how to avoid entering severe icing."
The answer is the same as avoiding thunderstorms: use the aircraft weather (WX) radar.
WX radar does not see clouds, but luckily it sees precipitations where severe icing exists.
All airline IPS can handle ice encountered in clouds, but no aircraft can maintain a flight in severe icing conditions.
On the ATR this precipitation shows as green blobs on the WX radar screen. Avoid them.
I think that the ATR IPS, even before Roselawn, was adequate to handle what the aircraft was certified for, by following the excellent Ice procedures that served me well for over 9000 hours of flying ATRs on three continents.
WX radar training must be integrated in learning how to fly in icing conditions.
It's almost impossible and in all my years in aviation maint I have never seen a proper pre flight of the stab boots. Those stab boots need constant inspection and maint and are notoriously unattended by both pilots and maint. Holes render the boots inop as they cannot inflate giving a warning indication. Those boots get little attention all summer and when winter kicks in their failure hate increases dramatically. If icing is possible the boots must be on for several cycles prior to flight.
.. Too Many "Cooks In The Kitchen" .. Your Group Presentation "Is Not Focused" On The Accident .. You're "Wandering-Off In Many Directions" Instead of "Concentrating" on The Flight Data and The Weather .. Very Confusing for Your Audience .. We Want "The Bottom Line" .... Compare Your Presentation to "Juan Browne's" .. He Sticks to "The Data & Weather" & Makes a Thorough Diagnosis & Summary ..🙏😇
Certification engineerThe controlling of the icing by the pilot cannotbesiccessively due to speed ofovongiwouldnotflyinthisaircrsft.I MY computer printer giving problems