19 fatalities

2006-03-31: Let L-410 (PT-FSE) — Transportes Especiais Aéreos & Malotes - TEAM — Rio Bonito, Brazil

Rio Bonito, BrazilFlight

On March 31, 2006, a Let L-410 (registration PT-FSE) operated by Transportes Especiais Aéreos & Malotes - TEAM was involved in an aviation accident near Rio Bonito, Brazil in flight. 19 people were killed. Investigators recorded the probable cause as: The crew performed controlled flight into terrain after choosing to fly under visual flight rules in weather conditions that were unsuitable for such operations. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781198972Data APIEditorial standards

A twin-engine aircraft crashed into a mountain peak during a flight from Macaé to Rio de Janeiro, resulting in the deaths of all 19 people on board.

What happened

A twin-engine aircraft departed Macaé Airport at 17:19 local time, bound for Rio de Janeiro-Santos Dumont Airport. The flight was carrying two pilots and 17 passengers. Shortly after takeoff, the co-pilot opted to cancel the IFR flight plan, electing to proceed under VFR rules while maintaining an altitude of 4,5able0 feet. As the aircraft approached São Pedro da Aldeia, air traffic control cleared the crew to descend to 2,000 feet due to deteriorating weather. While maneuvering near Saquarema, the crew attempted a left turn to bypass cloud cover. During this maneuver, at an altitude of 1,920 feet, the aircraft type struck Pedra Bonita Peak. The wreckage was located in a heavily forested area approximately six kilometers southeast of Rio Bonito. The impact resulted in the total destruction of the aircraft and 19 fatalities.

Findings

Investigations concluded that the accident was a case of controlled flight into terrain. Several contributing factors were identified regarding the crew's decision to operate under VFR conditions despite being in IMC (Instrument Meteorological Conditions). Key findings included:

  • The crew failed to perform an adequate meteorological assessment, neglecting the presence of low clouds and mist covering the Serra do Mar region.
  • There was a lack of proper situational awareness, leading the pilots to fly at altitudes below safe limits for visual flight.
  • The captain demonstrated overconfidence due to familiarity with the local geography.
  • A failure to adhere to established civil aviation rules and air traffic protocols was noted, specifically regarding intentional non-compliance with altitude and visibility standards.
  • Organizational deficiencies within the operator were identified, including a culture of complacency that allowed for unsafe flight procedures and a lack of effective safety oversight.

Probable cause

The crew performed controlled flight into terrain after choosing to fly under visual flight rules in weather conditions that were unsuitable for such operations.