33 Years ago today: On 21 March 1989 a Transbrasil Boeing 707 crashed into a residential area on approach to Sao Paulo, Brasil; killing all 3 crew and 22 people on the ground.
|Date:||Tuesday 21 March 1989|
|Leased from:||Omega Air Inc|
|First flight:||1966-06-09 (22 years 10 months)|
|Total airframe hrs:||61053|
|Engines:||4 Pratt & Whitney JT3D-3B|
|Crew:||Fatalities: 3 / Occupants: 3|
|Passengers:||Fatalities: 0 / Occupants: 0|
|Total:||Fatalities: 3 / Occupants: 3|
|Ground casualties:||Fatalities: 22|
|Aircraft fate:||Written off (damaged beyond repair)|
|Location:||2,7 km (1.7 mls) W of São Paulo-Guarulhos International Airport, SP (GRU) ( Brazil)|
|Departure airport:||Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG), Brazil|
|Destination airport:||São Paulo-Guarulhos International Airport, SP (GRU/SBGR), Brazil|
The Boeing 707-300 cargo plane departed Manaus, Brazil on a domestic flight to São Paulo-Guarulhos Airport carrying 26 tons of electronic equipment. The flight crew consisted of a captain under training, an instructor and a flight engineer.
The flight took off at 11:30 UTC and arrived in near Guarulhos Airport shortly before 15:00 UTC (12:00 hours local time). Since an aircraft had become immobilised on runway 09L, the aircraft was cleared for an approach to runway 09R. However, this runway was going to close for maintenance at 15:00 UTC.
A rushed high speed approach was flown. About 14:55 UTC the instructor selected full flaps and speedbrakes, leading to a loss of control.
The left wing of the aircraft struck a building. The aircraft crashed into a residential area near the intersection of Rua Rua Regente Feijó and Rua Sandovalina in the Jardim Ipanema neighborhood and burst into flames. Three crew members and 22 persons on the ground were killed.
This 707 was used in the 1970 movie “Airport” when it was still owned by Flying Tigers.
a. Human Factor
(1) Psychological aspect – the imminent interruption of operations in the aerodrome that would be used for landing the aircraft stimulated the instructor to make a hurried descent, characterizing a potential state of anxiety.
(2) Physiological aspect – there are indications that it contributed to fatigue
b. Material Factor – Did not contribute
c. Operational Factor – It was a determining factor for the occurrence of the accident through the following aspects:
(1) Poor instruction – The instruction given to the pilot was discontinued and the local flight did not comply with the minima provided in RAC 3211.
(2) Poor supervision – The failures found in the instruction were due to poor supervision of the Company’s operations sector.
(3) Poor cockpit coordination
– During the descent procedure when working check list, the instructor broke the sequence of standardized procedures, thus stopping the instruction and consequently, the student’s core handling of the flight
– The instructor, without the student being informed beforehand, commanded the flaps together with the “speed brake”. This action configured an abnormal attitude that contributed, without the pilots identifying, to the loss of control of the aircraft
– The flight engineer also failed to meet the checklist items.
(4) Pilot factor caused by other operational factors
– The instructor did not follow the standardization of the instruction, when he executed a decision in a hurry.
– The crew did not respond to the sinking and pull up warnings
(5) Pilot factor caused by error in the application of flight controls – The crew did not operate in accordance with the operational standard issued by the manufacturer and endorsed by the company.
(6) Other (Air Traffic Control) – The air traffic controller contributed to the increase of the crew anxiety level when the controller used non standard phraseology.