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."
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