Flight Details
The aircraft departed Presidente Juscelino Kubitschek Aerodrome (SBBR) in Brasília for Congonhas Aerodrome (SBSP) in São Paulo at 2039 UTC. The flight was a personnel transportation mission with two crew members and two passengers on board. During cockpit preparation, the crew commented about the operation of the Pitch Trim System. The earlier flight that day from São Paulo to Brasília had been conducted without abnormalities.
In-Flight Event
Approximately thirty minutes after takeoff from Brasília, while still climbing near flight level 370, the cockpit voice recorder captured a characteristic sound of the aircraft's horizontal stabilizer moving. Subsequently, the aircraft entered a downward trajectory with high speed and a high rate of descent until impact with the ground.
Damage and Occupants
The aircraft was destroyed. All four occupants perished at the site, including Lúcio Flávio de Oliveira and Marco Antonio Rossi, two directors of Banco Brasdesco.
Investigation Findings
The official investigation listed multiple contributing factors. Regarding control skills, it was considered undetermined whether the crew failed to operate the secondary pitch trim system switches after inadvertent stabilizer movement, as no Clacker warning sound was recorded. The emergency procedure for Pitch Trim Runaway or Failure may not have been performed; the crew may have relied only on elevator control or primary trim.
Attitude was also undetermined: the decision to fly without proper primary pitch trim and autopilot function may have stemmed from pilot self-confidence after a successful earlier flight. The updated Shutdown Checklist, which should include the Stabilizer Trim Backdrive Monitor test, may not have been executed after the previous flight, suggesting possible lack of adherence to procedures.
Crew Resource Management was a contributor: there was an absence of verbalization and communication regarding checklist actions and emergency management.
Training was undetermined: the lack of periodic simulator training, especially for Pitch Trim Runaway, may have affected crew performance.
Organizational culture was undetermined: the operator did not properly fill out the PT-WQH flight logbook, possibly failing to record a history of pitch trim system failures.
Piloting judgment was undetermined: takeoff with a possible failure in the pitch trim system indicated inadequate risk assessment.
Aircraft maintenance was undetermined: no clear link was established between maintenance in September 2015 and the accident, but incomplete crash surveys could not be ruled out.
The decision-making process was a contributor: the Warning Systems check item from the Cockpit Preparation Checklist was apparently not performed, preventing correct verification of the pitch trim system.
Interpersonal relationship was undetermined: CVR data suggested possible crew rush to take off despite known trim issues, though the source of pressure was not determined.
Support systems were undetermined: the pilots' abbreviated checklist may have been outdated, lacking the Stabilizer Trim Backdrive Monitor test procedure.
Managerial oversight was undetermined: records and control of operational check flights were not adequately performed, indicating possible weaknesses in supervision of maintenance activities.