Accident Overview
A night cargo flight from Porto Alegre to Joinville ended in a fatal crash after the aircraft struck a hill during descent. The accident occurred when the crew, unable to locate an inoperative navigation beacon, inadvertently turned toward a distant beacon and continued descending without detecting the heading change.
Sequence of Events
The crew departed Porto Alegre on a night cargo flight to Joinville. They selected the JNV NDB beacon and the next PP NDB to initiate the descent to Joinville Airport, with a minimum safe altitude set at 770 feet. After the aircraft passed over the JNV beacon, the ADF system could not find the PP NDB because it was inoperative. Consequently, the aircraft initiated a turn heading 051° toward the PP beacon located near São Paulo-Congonhas Airport. The crew did not notice the change of heading and continued the descent. A few minutes later, the aircraft struck a hill and crashed. Both pilots were killed.
Investigation Findings
The official investigation reported the following findings: possible crew fatigue that diminished their performances; possible psychological and organizational diminution; possible inadequate supervision of the operator in flight planning and non-compliance with procedures in force; following a lack of crew resources management, the crew failed to follow standard descent procedures; poor approach planning on the part of the crew; it is possible that the crew did not observe sufficient rest time; it is also possible that there was intentional disobedience by the crew of ATC rules and operational standards in relation to the use of GPS equipment during the descent, even though this was not approved for such procedure.