Preliminary Report on the Voepass ATR 72-500 Crash Released by Cenipa

Source: Aeroin.net 

On the evening of Friday, September 6th, 2024, the Brazilian Air Force’s Aeronautical Accidents Investigation and Prevention Center (Cenipa) released the preliminary report on the August 9th, 2024 crash of the Voepass ATR 72-500, registered as PS-VPB. This report provides initial details about the tragic accident.

You can read the preliminary report by clicking here. 

Preliminary Report

The aircraft departed from Colonel Adalberto Mendes da Silva Airport in Cascavel, Paraná, bound for Governor André Franco Montoro Airport in Guarulhos, operating a commercial flight with 58 passengers and four crew members onboard. While cruising over Vinhedo (São Paulo) during the flight, the crew lost control of the aircraft.

Our blog post: Voepass Flight 2283 Crash: Initial Details and Reports

According to the preliminary report released by Cenipa, both the aircraft and crew had valid certifications and were trained for in-flight icing conditions. No emergency call was made to air traffic control during the flight.

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Sequence of events

Based on the information collected at the initial field Investigation, as well as recordings from the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR), the Investigation Committee identified the sequence of events preceding the aircraft’s collision with the ground. The time reference utilized is UTC (Universal Time Coordinated).

• 14:58:05 - the aircraft initiated takeoff from the runway 15 of SBCA, with 58 passengers and 04 crew on board;
• 15:12:40 - the PROPELLER ANTI-ICING 1 and 2 were turned on;
• 15:14:56 - the Electronic Ice Detector connected to the Centralized Crew Alert System (CCAS) emitted an alert signal upon passing FL130;
• 15:15:03 - the AIRFRAME DE-ICING was turned on;
• 15:15:42 - a single chime was heard in the cockpit. Subsequently, the crew commented on the occurrence of an AIRFRAME DE-ICING Fault, and that they would turn it off;
• 15:15:49 - the AIRFRAME DE-ICING was turned off;
• 15:16:25 - the Electronic Ice Detector ceased emitting the alert signal.
• 15:17:08 - the Electronic Ice Detector emitted an alert signal.
• 15:19:13 - the Electronic Ice Detector stopped emitting the alert signal;
• 15:23:43 - the Electronic Ice Detector emitted an alert signal;
• 15:30:05 - the Electronic Ice Detector stopped emitting the alert signal.
• 16:11:02 - the Electronic Ice Detector emitted an alert signal;
• 16:12:41 - the Electronic Ice Detector stopped emitting the alert signal;
• 16:12:55 - the Electronic Ice Detector emitted an alert signal;
• 16:15:16 - the SIC (pilot Second in Command) made radio contact with the airline's operational dispatcher at Guarulhos airport, for coordination of the aircraft arrival;
• 16:16:25 - At the same time of the SIC’s coordination with the operational dispatcher, a flight attendant called over the intercom. The SIC asked her to hold on moment and continued speaking with the dispatcher;
• 16:17:20 - the Electronic Ice Detector stopped emitting the alert signal. At this time, the SIC was asking the flight attendant for information that would be passed to the operational dispatcher;
• 16:17:32 - the Electronic Ice Detector emitted an alert signal; at this time, the PIC was informing the passengers about the SBGR local conditions and estimated time of landing;
• 16:17:41 - the AIRFRAME DE-ICING was turned on;
• 16:18:41 - at a speed of 191 kt., the CRUISE SPEED LOW alert was triggered. Concomitantly, the SIC was about to finish relaying some information to the operational dispatcher;
• 16:18:47 - the PIC started the briefing relative to the approach for landing in SBGR. Concomitantly, APP-SP made a radio call, and instructed him to change to frequency 123.25MHz;
• 16:18:55 – a single chime was heard in the cockpit. At this time, the communication with APP-SP was taking place;
• 16:19:07 - the AIRFRAME DE-ICING was turned off;
• 16:19:16 - the crew made a call to APP-SP (São Paulo Approach Control) on the frequency 123.25 MHz;
• 16:19:19 - APP-SP requested the PS-VPB aircraft to maintain FL170 due to traffic;
• 16:19:23 - the crew replied to APP-SP that they would maintain flight level and that they were at the ideal point of descent, waiting for clearance;
• 16:19:28 - at a speed of 184 kt., the DEGRADED PERFORMANCE alert was triggered, together with a single chime. The alert was triggered concomitantly with the exchange of messages between APP-SP and the crew;
• 16:19:30 - APP-SP acknowledged the message and requested the aircraft to wait for clearance;
• 16:19:31 - Passaredo 2283 aircraft reported receipt of the message and thanked ATC;
• 16:19:33 - the PIC resumed delivering the approach briefing;
• 16:20:00 - the Second in Command (SIC) commented, “a lot of icing”;
• 16:20:05 - the AIRFRAME DE-ICING was turned on for the third time;
• 16:20:33 - APP-SP cleared the aircraft to fly direct to SANPA position, maintaining FL170, and informed that the descent would be authorized in two minutes;
• 16:20:39 - the crew acknowledged the flight instruction received (last communication performed by the flight crew);
• 16:20:50 - the aircraft started a right turn in order to fly to SANPA position.
• 16:20:57 – during the turn, at a speed of 169 kt., the INCREASE SPEED alert was triggered, in conjunction with a single chime. Immediately afterwards, vibration noise was heard in the aircraft, simultaneously with the activation of the stall alert;
• 16:21:09 - control of the aircraft was lost, and it entered an abnormal flight attitude until colliding with the ground. The aircraft rolled to the left to a bank-angle of 52 degrees, and then rolled to the right to a bank-angle of 94 degrees, performing a 180-degree turn in a clockwise direction. Subsequently, the turn was reversed to an anticlockwise direction, with the aircraft completing five full rotations in a flat spin before crashing into the ground.

Throughout the flight, the ice warning was activated and deactivated several times, with a 10-second alert duration followed by 2-minute intervals between activations.

The investigation into the causes of the accident is ongoing, and a final report will be published upon the completion of the work, which may take more than a year, depending on the case's complexity.

Written in collaboration with Aeroin (Brazil)