What happened
A cargo flight transporting 26 tons of electronic equipment was performing an approach to São Paulo. The crew, consisting of an instructor, a captain under training, and a flight engineer, was originally cleared for runway 09L. However, due to an aircraft blocking that runway, they were redirected to runway 09R. The crew was aware of a NOTAM indicating that runway 09R was scheduled to close at 1200LT for maintenance work.
During the approach, the instructor interrupted the training session and performed rapid maneuvers, including the simultaneous deployment of flaps and speed brakes. This caused an uncontrolled descent. The aircraft's left wing collided with a residential rooftop before the plane crashed into a neighborhood approximately 2.7 km before reaching the runway. The impact resulted in a post-crash fire. The accident caused 25 fatalities, including all three crew members and 22 individuals on the ground, while 47 people on the ground sustained serious injuries.
Findings
The investigation identified several contributing factors related to crew performance and operational pressure. The impending runway closure created a sense of urgency that led the instructor to execute a hurried descent. This maneuver disrupted standardized procedures and interrupted the training instructions being provided to the student pilot.
Key findings included:
- Poor coordination between the crew members and failure to follow checklist items by both the instructor and flight engineer.
- The simultaneous use of flaps and speed brakes created an abnormal aircraft attitude that led to a loss of control.
- The crew failed to respond to sinking and pull-up warnings.
- Potential crew fatigue and a lack of adherence to manufacturer-endorsed operational standards.
- The instructor's rushed decision-making and deviation from standardized flight instruction protocols.
- Use of non-standard phraseology by air traffic control, which increased the crew's anxiety levels.