Created Friday, Aug 9th 2024 17:42Z, last updated Friday, Jul 24th 2026 13:27Z
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."
On Jul 23rd 2026 CENIPA released their final report concluding the probable causes of the crash were:
- Handling of aircraft flight controls – a contributor.
The pilots’ pitch control inputs in the nose-up direction during the activation of the stall warning, contrary to the procedures prescribed in the QRH and in UPRT training, contributed to the increase in AOA and to the aggravation of the stall condition.
- Attention – a contributor.
During a significant portion of the flight, the pilots remained engaged in informal conversations unrelated to the technical and operational conduct of the aircraft, which reduced the flight crew’s attentional focus both on monitoring the external environment, characterized by the presence of conditions conducive to severe ice formation, and on observing the indications and alerts activated in the cockpit. This state of distraction favored the onset of inattentional blindness and inattentional deafness.
- Attitude – a contributor.
Despite prior awareness of the failure in the Airframe De-Icing system and the forecast of conditions conducive to severe ice formation along the route, the flight crew chose to proceed with the flight as planned, without adopting mitigating measures intended to reduce the risk inherent to operations under such atmospheric conditions. This conduct evidenced an attitude characterized by disregard for applicable operational aspects and procedures, contributing to the aircraft’s exposure to a high-risk scenario.
Additionally, the pilots failed to execute operational procedures prescribed in the QRH throughout the flight, such as the DE ICING AIRFRAME FAULT procedure, still during the climb to cruise level, as well as those related to the APM system advisories/alerts (CRUISE SPEED LOW, DEGRADED PERFORMANCE, and INCREASE SPEED). This conduct reflected an inadequate posture on the part of the flight crew, suggesting tacit acceptance of deviations from established operational standards, contributing to the escalation of operational risk throughout the flight and, consequently, to the chain of events that culminated in the accident.
- Qualification and Training – undetermined.
Although the pilots had completed the training required by the regulatory requirements related to operations under conditions conducive to severe ice formation and upset prevention and recovery training (UPRT), the actions observed during the accident flight were not consistent with the theoretical and practical knowledge expected from such training.
Within this context, the pilots did not recognize in a timely manner the severity of the condition being faced, did not respond adequately to the risks associated with the recurrent alerts, and ultimately acted on the flight controls in a manner divergent from that prescribed in training.
- Adverse meteorological conditions – a contributor.
The meteorological conditions contributed to the configuration of the occurrence scenario, creating an environment unfavorable to the safe operation of the aircraft.
Prolonged exposure to severe icing conditions (SEV ICE) resulted in a significant increase in aerodynamic drag and degradation of aircraft performance, with a direct impact on cruise speed and on the ability to maintain the desired flight regime.
- Crew Resource Management – a contributor.
The inadequate management of the tasks assigned to each crew member, the failure in communication, and the noncompliance with operational standards characterized inefficiency in cockpit coordination, in which threat management was not jointly mitigated, thereby favoring the continuation of the flight in an environment of increasing risk, even in the presence of successive aircraft performance degradation alerts issued by the APM, contributing to the accident.
- Work-group culture – a contributor.
The frequent occurrence of advisories and alerts, especially those related to the APM system, generated complacency within the company’s pilot group, culminating in reduced vigilance, and relaxation in the face of their high repetitiveness. Within this context, the company’s pilot group tended to underestimate the APM system advisories/alerts, supported by a false sense of safety justified by previous experience in which no consequences had been associated with such actions.
- Organizational culture – a contributor.
The company’s organizational culture of failing to properly address the information made available through the PAADV, as well as failing to use it in risk management and in the adoption of mitigating actions, influenced the behavior of the flight crews with regard to the importance attributed to the aircraft alerts.
Thus, the pilots’ decisions during the accident flight were influenced by an organizational context marked by multiple vulnerabilities in the safety culture, in which the acceptance of deviations had become normalized and the aircraft alerts had become trivialized, reducing risk perception.
- Emotional state – undetermined.
According to the CVR recordings and the accounts obtained throughout the investigation, the PIC was facing, at the time of the accident, personal problems that were negatively affecting his operational performance. This emotional state may have influenced his behavior during the flight, reducing his engagement in the critical decisions of the operation and diverted his attentional focus from the stimuli relevant to the safe conduct of the aircraft.
- External influences – undetermined.
The personal problems faced by the PIC at the time of the occurrence, which became the subject of informal conversations between him and the SIC during the flight, diverted his attentional focus from stimuli related to the operation and reduced his risk perception, given that such dialogues occurred even during critical moments of the operation, such as during or immediately after the onset of the performance loss advisories/alerts, thereby influencing his operational performance.
- Piloting judgment – a contributor.
At no point during the flight did the pilots request an immediate descent or declare an emergency situation due to the ice accumulation and performance degradation condition.
This omission, combined with the non-execution of the actions prescribed in the operational procedures in response to the performance degradation advisories/alerts issued by the aircraft, indicated that the flight crew performed an inadequate assessment of parameters related to the safe operation of the aircraft, which resulted in the absence of the necessary actions to manage the conditions encountered.
Furthermore, the acceptance of conducting the flight in known icing conditions in an aircraft that was knowingly operating with the Airframe De-Icing system inoperative, as well as the non-execution of the procedures prescribed for the triggering of the various APM advisories, revealed an inadequate assessment of parameters related to the operation of the aircraft, despite the crew's qualifications to operate it.
- Aircraft maintenance – a contributor.
The absence of formal recording in the TLB following the onset of in-flight failures, especially with regard to the malfunction of the Airframe De-Icing system on the flights preceding the accident, prevented the company’s technical and operational sectors from implementing mitigating measures, such as dispatch under the MEL, aircraft substitution, route replanning, or even corrective maintenance to resolve the malfunction, thereby contributing to the aircraft operating under meteorological conditions conducive to ice formation with the Airframe De-Icing system inoperative.
- Perception – a contributor.
Impairments were identified in the flight crew’s ability to recognize, comprehend, and project the sensations arising from internal and external stimuli within the operational environment, such as meteorological information related to severe ice formation, indications of performance loss, and advisories/alerts issued by the APM, which led to reduced situational awareness and delayed perception of the risk to which they were exposed, thereby impairing the issuance of responses compatible with the severity of the situation.
- Flight planning – a contributor.
The flight planning process did not involve effective integration among the responsible sectors, nor did it include continuous and proactive support from the CCO, failing to mitigate foreseeable risks arising from documented hazards. This gap constituted a contributing factor in maintaining the aircraft at a flight level susceptible to ice accretion, culminating in the progressive degradation of performance and in the development of the occurrence scenario.
- Decision-making process – a contributor.
The decision to conduct cruise flight at FL170, a flight level at which severe ice formation had been forecast, without questioning or adapting the planning to the identified meteorological scenario, evidenced difficulties in the flight crew’s process of analyzing and selecting alternatives.
This condition manifested itself even more critically during the cruise phase, when, despite the successive performance degradation advisories/alerts issued by the APM, including the DEGRADED PERFORMANCE and INCREASE SPEED alerts, the pilots did not adopt any structured action prescribed in the operational procedures, nor did they request an immediate descent or declare an emergency situation.
Such conditions indicated that the flight crew experienced difficulties in adequately analyzing the ongoing situation, selecting the available alternatives, and acting in a timely manner, characterizing inadequate decision-making in the face of a progressively increasing risk scenario, which contributed to the evolution of the events leading to the loss of control of the aircraft.
- Organizational processes – a contributor.
The underutilization of the information made available through the PAADV, which was frequently neither analyzed nor incorporated into risk management, especially information related to performance degradation due to ice accretion, combined with the absence of realtime support from the CCO to the pilots regarding meteorological conditions along the route, demonstrated that the organizational processes were not consolidated as effective risk mitigation instruments.
This set of weaknesses favored the adoption of a passive posture in response to the alerts and inhibited the structured actions prescribed in the operational procedures.
- Design – undetermined.
The INCREASE SPEED alert was activated in a situation requiring immediate corrective action by the flight crew, in which the aircraft indicated airspeed was close to the VmLB0icing, thus representing an operating condition near the minimum controllable limit, consistent with the criteria established by the manufacturer for a level 3 alert message (WARNING).
The fact that the INCREASE SPEED alert was categorized as a level 2 alert (CAUTION) by the manufacturer may have led flight crews to underestimate the severity of the condition to be managed.
- Managerial oversight – a contributor.
The absence of effective managerial oversight regarding the use of the information made available through the PAADV, which was not adequately analyzed nor incorporated into risk management and the adoption of mitigating actions, especially those related to performance degradation due to ice accretion, evidenced inadequate oversight by the organization’s management of operational planning and execution activities. As a result, more robust preventive measures were not adopted prior to the occurrence, allowing the escalation of risks, contributing to the flight crew adopting a passive posture in response to the alerts, thereby delaying the structured actions prescribed in the operational procedures.
- Other / ANAC Actions – a contributor.
The audits and inspections conducted by ANAC on the operator prior to the accident revealed several technical and procedural nonconformities related to aircraft maintenance, component traceability, noncompliance with MEL conditions, and the recurrent practice of informal reporting or non-reporting of malfunctions.
The findings of the SIPAER Investigation Commission indicated that the signs identifying hazards, degradation of technical conditions, and latent conditions prior to the accident were not capable, when analyzed within the scope of ANAC’s risk management process, of supporting the strategic decision-making necessary for the mitigation and control of risks in the operational environment regulated and overseen by the Agency.
Thus, it is possible to conclude that the means for recording, processing, and monitoring data and information related to hazards for the purpose of risk management were still in a maturation phase, allowing the continuity of the company’s operations despite degradation of the safety levels.
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=
Ground observer videos:
Situation on the ground:
Map (Graphics: AVH/Google Earth):
Details Maps (Graphics: AVH/Google Earth):
Map with amber overlay showing the severe icing zone based on SBBS SIGMET 2 (Graphics: AVH/Google Earth):
Map with amber overlay based on SBBS SIGMET 2 and yellow overlay based on SBCW SIGMET 9 (Graphics: AVH/Google Earth):
Satellite Image GOES-E-16 Band 11/Top Clouds Aug 9th 2024 16:20Z (Graphics: AVH/NASA):
Satellite Image GOES-E-16 Band 5/Snow-Ice Aug 9th 2024 16:20Z (Graphics: AVH/NASA):
FDR data (Graphics: CENIPA):
FCOM page "Severe Icing" (Graphics: CENIPA):
