Cargo Flight Crash in São Paulo Residential Area (PT-TCS)

Incident Overview and Crew Composition The aircraft was operating a cargo flight from Manaus to São Paulo when it crashed into a residential area. The crew consisted of a captain under training, an instructor, and a flight engineer. The aircraft was carrying a load of 26 tons of electronic equipment at the time of the accident. The crash occurred approximately 2.7 km short of the runway, and the aircraft burst into flames after the left wing struck the roof of a house. The accident resulted in the deaths of all three crew members and 22 people on the ground, with 47 additional people on the ground seriously injured. ## Approach and Runway Changes Initially, the crew was cleared for an approach to runway 09L. However, they were instructed to change to runway 09R because runway 09L was blocked by an aircraft. The crew was aware of a NOTAM indicating that runway 09R would be closed to all traffic starting at 1200LT due to maintenance. Under these conditions, the instructor rushed the approach procedure, interrupted the instruction to the captain under supervision, and commanded flaps and speed brake at the same time, causing the aircraft to descend. ## Official Findings and Contributing Factors The official investigation identified a combination of factors that contributed to the accident. The imminent closure of runway 09R due to maintenance stimulated the instructor to make a hurried descent, characterizing a potential state of anxiety. Probable crew fatigue was also noted. The instruction given to the pilot was discontinued, and the local flight did not comply with the minima provided in RAC 3211. Failures in the instruction were attributed to poor supervision of the company's operations sector. Poor crew coordination was identified, and during the descent procedure, the instructor broke the sequence of standardized procedures, stopping the instruction and the student's core handling of the flight. The instructor commanded the flaps together with the speed brakes without informing the student beforehand, configuring an abnormal attitude that contributed to the loss of control of the aircraft without the pilots identifying it. The flight engineer also failed to meet checklist items. The instructor did not follow the standardization of the instruction when executing a decision in a hurry. The crew did not respond to sinking and pull-up warnings, and there was an error in the application of flight controls. The crew did not operate in accordance with the operational standard issued by the manufacturer and endorsed by the company. The air traffic controller contributed to the increase of the crew's anxiety level by using non-standard phraseology.