Total Linhas Aéreas flight 5561

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Total Linhas Aéreas flight 5561
ATR ATR-42-300, Total Linhas Aereas AN0559614.jpg

An ATR 42-312 from the airline, similar to the aircraft involved in the accident
Accident summary
Accident type Loss of control
place 38 kilometers southwest of Paranapanema , BrazilBrazilBrazil 
date September 14, 2002
Fatalities 2
Survivors 0
Aircraft
Aircraft type FranceFranceItalyItaly ATR 42-312
operator BrazilBrazil Total Linhas Aéreas
Mark BrazilBrazil PT-MTS
Departure airport Sao Paulo-Guarulhos Airport , BrazilBrazilBrazil 
Destination airport Londrina Airport , Brazil
BrazilBrazil 
Passengers 0
crew 2
Lists of aviation accidents

The total Linhas Aéreas-Flight 5561 was a domestic cargo flight of the Brazilian airline Total Linhas Aéreas from São Paulo-Guarulhos to Londrina Airport , where it crashed one on 14 September 2002 ATR 42-312 came after the crew had lost control of the machine. The two pilots were killed in the crash.

machine

The aircraft concerned was an ATR 42-312, a model of the Italian-French consortium Avions de Transport Régional (ATR) founded by Aeritalia and Aérospatiale for the construction of regional aircraft . The machine was 16 years old at the time of the accident. It had the model serial number 026, was finally assembled at the ATR production site in Toulouse and completed its maiden flight on September 15, 1986 with the test registration F-WWEE . The machine was leased from the manufacturer to Air Guadeloupe on October 29, 1986 and carried the aircraft registration F-OGNE . From April 1999 ATR leased the machine to the Régional Compagnie Aérienne Européenne , whereby the machine was given the F-GTSM label on this occasion . The Régional leased the aircraft to Air Open Sky on June 6, 1999 , before the aircraft returned to its fleet as a lease return on March 24, 2000. From June 7, 2000, ATR leased the aircraft to Air Atlantique . On September 13, 2001, the aircraft was sold to Total Linhas Aéreas, where it received its last aircraft registration PT-MTS . The twin-engine regional transport aircraft was equipped with two turboprop engines of the type Pratt & Whitney Canada PW120 equipped. Up to the accident, the machine had completed 33,371 operating hours, which accounted for 22,922 take-offs and landings.

Crew and purpose of flight

There was only a two-person crew on board, consisting of a flight captain and a first officer. The flight was a mail flight.

Flight history

The machine took off at 4:52 a.m. local time in São Paulo. At 05:12:30, the crew asked for clearance to climb to 16,000 feet. At 05:13:18, the copilot said: “Damn it, it's the cable harness.” The meaning of this statement could not be determined later. At 05:16:03, clearance was given to climb to 18,000 feet. At 05:29:14 the master informed the first officer that he would change and left his cockpit seat. At 05:37:32, the “Event” button in the center console was pressed, with which the crews can register the occurrence of an anomaly in flight on the flight data recorder . Five seconds later, the autopilot switched itself off and the trim wheel began to point the machine with the aircraft's nose pointing towards the ground. While the engine was sinking, the master asked the first officer twice at 05:37:38 and 05:37:46 what was going on, whereupon the officer replied that he did not know. Eight seconds later, the captain stated that the pitch trim system was trimming the aircraft nose down. Then a seat belt buckle clicked, which the accident investigators interpreted as the captain's return to his seat. Between 05:37:40 and 0537:46, one of the pilots also tried to stop the descent by pulling the control horn.

At 05:37:55, the master called to the first officer to "pull the trim", by which he meant that the circuit breaker of the trim system should be pulled. This is located in type ATR 42 machines on a control panel behind the first officer and is inaccessible to the master. The first officer did not understand this instruction at first, whereupon the master repeated it several times. In the meantime, the pitch trim was adjusted up to its final stage of five degrees. At 0538:05, the first officer stated that he had pulled the circuit breaker, which was also confirmed by the data from the flight data recorder.

The machine was at an altitude of 16,000 feet and its airspeed had increased from 180 knots to 260 knots. At 05:38:37, the warning signal sounded, which indicated that the airspeed exceeded the maximum permissible airspeed for the aircraft structure. The pilots then reduced the engine thrust from the cruise configuration to 10 percent.

Between 05:38:29 and 05:38:49 the master asked the first officer to pull the trim while he continued to pull the steering column himself. The cockpit voice recorder (CVR) recorded noises that indicated that the aircraft was accelerating further. The recording ended at 05:39:10. The machine fell to the ground at a speed of 366 knots (approx. 678 km / h) and a left roll angle of 30 degrees with a pitch angle of approximately 45 degrees. The aircraft was completely destroyed and both crew members were killed.

Accident investigation

In its final report on the aircraft accident published on March 30, 2007, the Brazilian aircraft accident investigation authority CENIPA found that the aircraft had taken off with a weight of 16,649 kg including 4,720 kg of cargo. The weight was within the permissible range and 51 kg below the maximum take-off weight for the type of aircraft used. The weight distribution within the machine complied with the regulations and the weather could not be ascribed any role in the crash.

After evaluating the recordings from the cockpit voice recorder, the investigators came to the conclusion that the flight captain had never left the aircraft's cockpit. The fact that the captain had got out of his seat and the inadequate communication between the two pilots at the time of the accident were considered to be contributing factors to the accident, as it meant that time had passed that the pilots could have needed to find a solution to what had occurred Problem with the trim to consider. The crew was not trained to deal with a failure of the trim system and corresponding instructions on how to proceed in such a case were also missing in the manufacturer's operating manual. These circumstances were also seen as contributing factors.

Investigators concluded that the "event" switch was probably activated unintentionally. Neither of the two pilots commented on the activation of the switch and the evaluation of the flight data recorder did not reveal any anomalies at the time the button was activated that would have justified such an action. It is possible that the first officer accidentally activated the switch when trying to reach the emergency switch for the trim system, which was placed directly next to it. The flight data recorder did not record any activation of the emergency switch for the trim system.

Evaluations of the operating history of the ATR 42 showed that the trimming system had failed more frequently on machines of this type in the past. The incidents resulted in airworthiness directives from the Federal Aviation Administration and the DGAC .

The exact source of the error could not be determined. According to the investigators, the problem most likely occurred in the area of ​​the “system relays, switches, wires and connections”, which triggered the tilt compensation system. The report also criticized the fact that the main and emergency pitch trim systems were not operating independently and that the system had poor tolerance for errors.

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