The Preliminary Report was first presented to family members and then released at a press conference
CECOMSAER – CENIPA, by Lieutenant Monique Queiroz
This Friday (06/09), in Brasília (DF), the Center for Investigation and Prevention of Aeronautical Accidents (CENIPA), a Military Organization of the Brazilian Air Force (FAB), released the Preliminary Report of the aeronautical accident involving the aircraft registration PS-VPB, which occurred on August 9, 2024, in Vinhedo (SP).
The Preliminary Report was first presented to family members and then released at a press conference. The main purpose of the event was to present the main factual data on the progress of the investigations.
The Commander of the Air Force, Air Brigadier Marcelo Kanitz Damasceno, opened both presentations by emphasizing CENIPA’s commitment to transparency and seriousness in conducting the investigations, as well as respect for the grief of the families of the victims involved in the accident.
The ATR 72 aircraft of flight 2283 took off from Cascavel (PR) bound for Guarulhos Airport with 58 passengers and 4 crew members on board. The flight went smoothly until 1.20pm (Brasília time).
However, from 1.21 p.m. onwards, the aircraft stopped responding to calls from São Paulo Approach Control (APP-SP). Radar contact was lost at 1.21 p.m., and the moment of collision with the ground occurred at 1.22 p.m.
According to the Department of Airspace Control (DECEA), the Rescue Coordination Center (RCC), known as SALVAERO, was called at 1:26 p.m. and found the aircraft inside a condominium in the municipality of Vinhedo (SP).
CENIPA received notification of the accident at 1:37 p.m. and immediately called in investigators from the Fourth Regional Service for the Investigation and Prevention of Aeronautical Accidents (SERIPA IV), a military organization subordinate to CENIPA, located in São Paulo (SP).
After confirming that the aircraft had crashed, CENIPA, the central body of the Aeronautical Accident Investigation and Prevention System (SIPAER), and the Brazilian state authority responsible for conducting investigations into aeronautical incidents, began work with a multidisciplinary team made up of investigators and specialists in the following areas: Operational Factor (pilots, meteorologists, air traffic control specialists, aircraft maintainers), Human Factors (doctors and psychologists) and Material Factor (mechanical, aeronautical and electronic engineers, as well as other areas of engineering).
The team also includes Technical Consultants, including specialists in certification and aviation regulation, representatives of the French Research Agency (Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile – BEA), the country of origin of the ATR company, responsible for the design and manufacture of the aircraft, experts from the Transportation Safety Board of Canada (TSB), the country of origin of Pratt & Whitney Canada, responsible for the design and manufacture of the engines, as well as authorities from the European Aviation Safety Agency (EASA).
The work carried out by CENIPA is aimed solely at accident prevention, as established in art. 86-A of Law 7.565/1986 (Brazilian Aeronautical Code – CBA), as well as § 6, art. 1, of Decree 9.540/2018 and Annex 13 to the 1944 Convention on International Civil Aviation, to which Brazil is a signatory.
In this sense, the investigations carried out by CENIPA do not seek to establish guilt or liability, as provided for in § 4, art. 1, of Decree No. 9,540/2018, nor do they set out to prove any probable cause of an accident, but rather indicate possible contributing factors that allow for the elucidation of any technical issues related to the aeronautical occurrence.
In this way, by issuing Safety Recommendations, CENIPA proposes the implementation of measures to prevent the recurrence of similar events, seeking to improve flight safety.
During the Data Collection work, the Investigation Commission identified a sequence of events that preceded the aircraft’s collision with the ground, based on the information collected during the initial action, as well as the Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR).
The data from the recorders was obtained and extracted at CENIPA’s Laboratory for Reading and Analyzing Data from Flight Recorders (LABDATA). The voice data was validated by comparing information from conversations between pilots and Air Traffic Control agencies, as well as identifying the times and destinations reported.
From the analysis of the communications recorded by the CVR, it was possible to verify that the crew members commented on a failure in the DE-ICING system. This system provided protection against the formation and accumulation of ice on the aircraft. With the recordings obtained by the FDR, it was also found that the AIRFRAME DE-ICING system, responsible for preventing ice build-up on the wings, was switched on and off several times.
The investigator-in-charge of the Investigation Commission, Lieutenant Colonel Paulo Mendes Fróes, presented the work carried out so far. “It’s important to note that there is no single factor for an accident, but several contributing factors.
In the case of PS VPB, the loss of control of the aircraft occurred during flight under conditions favorable to the formation of ice, but there was no declaration of emergency or report of adverse weather conditions,” explained Lieutenant Colonel Fróes.
Based on the upper air atmospheric data, it was possible to identify that there was a lot of humidity combined with air temperature below 0°C, which favored the occurrence of severe Aircraft Ice Formation (AIF), from the center-north of Paraná (PR) to São Paulo (SP), initially reaching the layer between Flight Level (FL) 120 and (FL) 140, with its top reaching level (FL) 230 at the front edge of the system in São Paulo (SP).
“Weather information was available before take-off time; the pilots had more than 5,000 total flight hours and had all valid licenses and certifications. The aircraft, manufactured in 2010, was certified for flight in icing conditions, and the pilots had specific training for this type of flight. The PS VPB crew also included two flight attendants. Both had a Flight Attendant’s License (CMS) and had current qualifications for the AT47 type aircraft,” said the Investigator in Charge.
The ATR 72-212A, commercially designated as ATR 72-500, was registered in the Regular Public Air Transport Registration Category (TPR), and was certified and equipped with systems that allowed it to operate in adverse environmental conditions, including icing conditions.
“New data is in the process of being collected for subsequent validation, in order to support the analysis, so as to guarantee the accuracy and reliability of the conclusions that will be presented in the Final Report,” added Lieutenant-Colonel Fróes.
Based on the data obtained from the FDR and CVR recordings, the information gathered from the aircraft operator and its manufacturer, the investigation will follow three main lines of action: Human Factors – which will explore the individual, psychosocial and organizational factors related to the performance of the technical crew in the situation experienced; Material Factor – which will investigate the airworthiness condition, with special attention to the aircraft’s Anti-Icing, De-Icing and stall protection systems; and Operational Factor – which will analyze aspects related to the technical performance of the crew and elements related to the operational environment in the context of the accident.
The head of CENIPA, Air Brigadier Marcelo Moreno, stressed that “the information available in the Preliminary Report may be updated as new factual data is obtained. Our goal is to deliver the Final Report in the shortest time possible, always depending on the complexity of the occurrence and the need to uncover possible contributing factors,” said Brigadier Moreno.
At the end of the process, CENIPA will publish the Final Report, in accordance with Annex 13 of the Convention on International Civil Aviation, which will present the results obtained by the SIPAER Investigation in relation to the circumstances that contributed or may have contributed to triggering the accident, issuing any recommendations aimed at improving flight safety.
“CENIPA’s main objective is to ensure that all the lessons learned from this tragic event are captured in the Final Report and in the appropriate Safety Recommendations, with a view to preventing the recurrence of events of this nature, as well as the harmonious and safe development of air transport for society as a whole,” concluded the Brigadier.
Access the Preliminary Report here.
Final Report
The FAB stresses that the final investigation report will be released as soon as possible, depending on the complexity of the incident. When completed, the Final Report will be published on CENIPA’s website. For this and other information, visit the SIPAER Dashboard or click on the link:
https://painelsipaer.cenipa.fab.mil.br
Photos: Sergeant P. Silva / CECOMSAER