Voepass AT72 at Sao Paulo on Aug 9th 2024, spun out of control and lost height

Last Update: September 7, 2024 / 08:19:56 GMT/Zulu time

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Photo of VoePass Linhas Aereas PS-VPB, ATR ATR-72-200 — VoePass Linhas Aereas PS-VPB, ATR ATR-72-200 (Photo modified based on photo from IndiaEcho / Wikimedia Commons / License: CC by)

Incident Facts

Date of incident
Aug 9, 2024

Classification
Crash

Airline
VoePass Linhas Aereas

Flight number
2Z-2283

Departure
Cascavel, Brazil

Destination
Sao Paulo Guarulhos, Brazil

Aircraft Registration
PS-VPB

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A Voepass Linhas Aereas Avions de Transport Regional ATR-72-212A, registration PS-VPB performing flight 2Z-2283 from Cascavel,PR to Sao Paulo Guarulhos,SP (Brazil) with 58 passengers and 4 crew, was in the initial approach at about FL170, when the aircraft spun out of control and crashed into a residential area in Vila Santa Fe, Vinhedo,SP (Brazil) about 7nm southeast of Viracopos Airport and about 40nm northwest of Guarulhos Airport, approximate coordinates S23.050 W47.020, at about 13:22L (16:22Z). The aircraft broke into several parts and burst into flames. All occupants perished in the crash. No residential houses were hit, there were no injuries on the ground.

The airline confirmed the aircraft carrying 58 passengers and 4 crew had an accident near Vinhedo,SP (Brazil), circumstances of the accident as well as situation of the people on board are yet unknown. The airline later reported there were actually 57 passengers and 4 crew on board, unfortunately all have died in the accident. The aircraft had departed Cascavel without any flight restrictions and with all systems ready to carry out the operation.

On Aug 10th 2024 the airline confirmed a 62nd person was on board, who had not been registered due to a technical problem regarding check-in validation, boarding validation and counting of people on board.

Hospitals at Vinhedo and Valinhos had been put on alert to receive possible injuries.

Local Authorities reported although the aircraft crashed near residences with people inside, no people on the ground have been injured.

FAB Brazil, ATC provider, reported that the flight was normal until 16:20Z, however thereafter there was no communication from the aircraft anymore and the crew did not respond to calls, there was also no emergency call or pilot report of adverse weather conditions. The radar contact was lost at 16:22Z.

Brazil's CENIPA have opened an investigation. CENIPA later announced that they have recovered both the flight data and cockpit voice recorder, the black boxes are being sent to Brasilia,DF where they will be read out and analysed. In a press conference CENIPA confirmed the aircraft carrying 61 people had not issued an emergency call.

On Aug 11th 2024 emergency services reported they have completed their tasks at the crash site, all bodies have been recovered, the engines and the tail have been removed for examinations, and the wreckage site has been handed to CENIPA for further removal and analysis of the wreckage.

Later on Aug 11th 2024 CENIPA reported in a press conference, that both black boxes have been successfully and completely downloaded and validated, the data are now being analysed. The engines of the aircraft are being examined to determine whether they were operating at the time of impact. Investigators from the French BEA have arrived on site to join the investigation. Investigators from the Canadian TSB, the engines were manufactured in Canada, are expected at CENIPA headquarters shortly. A preliminary report can be expected 30 days after the crash.

On Aug 12th 2024 Brazilian Media reported that the aircraft had been in trouble ever since Mar 11th 2024, when it suffered a tail strike receiving structural damage. After its return to service 4 months later and one month prior to the crash passengers complained about the air conditioning system not working with incredible heat on board. See: Accident: Voepass AT72 at Salvador on Mar 11th 2024, hydraulic problems and tail strike on landing.

ADS-B data show, the aircraft had been enroute at FL170 and was just beginning the initial descent at 16:21Z when the flight data became erratic coinciding with the ground observer videos of a flat spin. The aircraft climbed again to FL172 before beginning the final rapid descent.

On Sep 6th 2024 CENIPA released their preliminary report summarizing the sequence of events:

Based on the information collected during the initial action, as well as the recordings from the Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR), the Investigation Commission identified the sequence ofevents that preceded the collision of the aircraft with the ground. To record the times described in this field, Universal Time Coordinated (UTC) was used as a reference.

14:58:05 - the aircraft began takeoff from runway 15 of SBCA, with 58 passengers and 4 crew members onboard;

15:12:40 – PROPELLER ANTI-ICING 1 and 2 were turned on;

15:14:56 - the Electronic Ice Detector connected to the Centralized Crew Alert System (CCAS) displayed awarning signal when crossing FL130;

15:15:03 - AIRFRAME DE-ICING was turned on;

15:15:42 - a single chime was heard in the cabin. The crew then reported that a Fault message had occurred on the DE-ICING AIRFRAME;

15:15:49 - AIRFRAME DE-ICING was turned off;

15:16:25 - the Electronic Ice Detector stopped displaying the warning signal;

15:17:08 - the Electronic Ice Detector displayed a warning signal;

15:19:13 - the Electronic Ice Detector stopped displaying the warning signal;

15:23:43 - the Electronic Ice Detector displayed a warning signal;

15:30:05 - the Electronic Ice Detector stopped displaying the warning signal;

16:11:02 - the Electronic Ice Detector displayed a warning signal;

16:12:41 - the Electronic Ice Detector stopped displaying the warning signal;

16:12:55 - the Electronic Ice Detector displayed a warning signal;

16:15:16 - the Second in Command (SIC) made radio contact with the airline's operational dispatcher at Guarulhos airfield, in order to carry out the necessary coordination for his arrival;

16:16:25 - at the same time as the coordination with the operational dispatcher, a flight attendant wascalled over the intercom. The SIC asked her to wait a moment and continued communication with thedispatcher;

16:17:20 - the Electronic Ice Detector stopped displaying the warning signal. At that moment, the SIC wasrequesting information from the flight attendant in order to transmit it to the operational dispatcher;

16:17:32 - The Electronic Ice Detector displayed a warning signal. At this time, the Pilot in Command (PIC)was informing the passengers about the conditions and the estimated time for landing at SBGR;

16:17:41 - AIRFRAME DE-ICING was turned on;

16:18:41 - at 191 kt speed, the CRUISE SPEED LOW alert was displayed. Simultaneously, the SIC was finishing passing on some information to the operational dispatch;

16:18:47 - the PIC began the approach briefing for landing at SBGR. Concomitantly, São Paulo Approach Control (APP-SP) made a call and instructed him to change to frequency 123.25 MHz;

16:18:55 - a single chime was heard in the cabin. Simultaneously, communication with APP-SP was taking place;

16:19:07 - AIRFRAME DE-ICING was turned off;

16:19:16 - the crew made a call on frequency 123.25 MHz to APP-SP;

16:19:19 - APP-SP requested that PS-VPB maintain FL170 due to traffic;

16:19:23 - the crew responded to APP-SP that they would maintain the flight level and that they were at theideal descent point, awaiting authorization;

16:19:28 - at 184 kt speed, the DEGRADED PERFORMANCE alert was displayed, along with a single chime. The alarm was triggered concomitantly with the message exchanges between APP-SP and the crew;

16:19:30 - APP-SP said they were aware and asked to wait for authorization;

16:19:31 - Passaredo 2283 said he was aware and thanked us;

16:19:33 - the PIC continued to carry out the approach briefing ;

16:20:00 - SIC commented: “a lot of ice”;

16:20:05 - AIRFRAME DE-ICING was turned on for the third time;

16:20:33 - APP-SP authorized the aircraft to fly directly to the SANPA position, maintaining FL170. Itinformed that the descent would be authorized in two minutes;

16:20:39 - the crew compared the previous message (last communication made by the crew);

16:20:50 - the aircraft began a right turn towards the SANPA position heading;

16:20:57 - during the turn, at 169 kt speed, the INCREASE SPEED alert was displayed, together with a single chime. Immediately afterwards, vibration noises began in the aircraft, together with the activation of the stall alarm ;

16:21:09 - control of the aircraft was lost and it entered an abnormal flight attitude until it collided with theground. At this point, the aircraft tilted 52º to the left and then 94º to the right, making a 180º clockwiseheading variation. Then, the heading variation was reversed to the counterclockwise direction, completing 5turns in a “flat spin” until the collision with the ground.

The captain (ATPL) had accumulated a total of 5,248 hours and 665 hours on type, the first officer (ATPL) had accumulated a total of 5,143 hours and 3,543 hours on type. The report states: "Both pilots had completed theoretical and practical training and had undergone proficiency exams in a flightsimulator, which included emergency training and, in particular, flight management in icing conditions."

CENIPA also reported that the aircraft had been dispatched under minimum equipment list requirements with PACK 1 inoperative restricting the aircraft to FL170. CENIPA stated:

The operating procedure included the following:

need to calculate fuel considering aircraft consumption at FL100;

note highlighting that the engine torque related to the inoperative
Pack would increase; and

Power Lever (PL) adjustment required for the affected engine.

The report states: "Furthermore, according to the transcripts of the audio communications between the PS-VPB and the controlbodies, it was found that there was no declaration of emergency."

At the time of the crash a number of SIGMETs (Significant Weather Information) were in effect:

- SBCW SIGMET 9 VALID 091530/091930 SBCW - SBCW CURITIBA FIR SEV ICE FCST WI S2024 W05806 - S2204 W05801 - S2221 W05549 - S2359 W05525 - S2349 W05440 - S2418 W05416 - S2422 W05417 - S2439 W05316 - S2848 W04527 - S2645 W04345 - S2356 W04006 - S2140 W04452 - S2248 W04546 - S2314 W04552 - S2338 W04639 - S2307 W04734 - S2220 W04955 - S2020 W05127 - S1809 W05326 - S1823 W05638 - S2045 W05321 - S2209 W05437 - S2024 W05806 FL120/210 STNR NC=

- SBBS SIGMET 2 VALID 091530/091930 SBBS - SBBS BRASILIA FIR SEV ICE FCST WI S1809 W05326 - S2020 W05127 - S2220 W04955 - S2307 W04734 - S2338 W04639 - S2314 W04552 - S2248 W04546 - S2140 W04452 - S1804 W05226 - S1809 W05326 FL120/210 STNR NC=

Metars Viracopos Airport:
SBKP 091800Z 35005KT 9999 -RA FEW015 17/16 Q1018=
SBKP 091726Z 02006KT 9999 -RA FEW033 17/15 Q1018=
SBKP 091700Z 01007KT 4000 -RA BR FEW033 17/15 Q1019=
SBKP 091632Z 36007KT 4000 -RA BR NSC 17/15 Q1019=
SBKP 091600Z 02008KT CAVOK 17/15 Q1020=
SBKP 091500Z 04005KT 8000 FEW046 17/15 Q1021=
SBKP 091400Z 27003KT 4000 -RA BR NSC 18/16 Q1022=
SBKP 091337Z 27005KT 4000 -RA BR NSC 19/15 Q1022=
SBKP 091300Z 28008KT 7000 NSC 19/15 Q1021=
SBKP 091200Z 26007KT 5000 HZ NSC 20/16 Q1020=

Metars Guarulhos Airport:
SBGR 091800Z 01003KT 9999 -RA NSC 17/13 Q1018=
SBGR 091700Z 33009KT 9000 NSC 17/13 Q1019=
SBGR 091600Z 36006KT 8000 NSC 17/13 Q1019=
SBGR 091500Z 32006KT 7000 -RA NSC 18/14 Q1021=
SBGR 091420Z 30012KT 5000 -RA BKN040 OVC070 19/13 Q1021=
SBGR 091400Z 32009KT 8000 BKN040 OVC070 19/13 Q1021=
SBGR 091300Z 27008KT 9000 NSC 20/14 Q1021=
SBGR 091200Z 25001KT 9000 NSC 18/16 Q1020=