So many warnings... Voepass Flight 2283 preliminary report
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- Опубликовано: 17 сен 2024
- The preliminary report after the accident with Voepass flight 2283 is released. There are some surprises, and it leaves several questions about the operation of the aircraft. The preliminary report reveals that the aircraft was dispatched into forecasted severe icing, a condition outside the certification of the aircraft. Early in the flight, a critical ice protection system failed. And when the Aircraft Performance Monitoring (APM) system triggered warnings about loss of performance, the crew did not act. Finally, the aircraft had lost so much speed that the stall alert was triggered. The crew did not apply the correct procedure to recover, and they lost control.
This video is based on the preliminary report issued on the 6th of September 2024 by the Aeronautical Accidents Investigation and Prevention Center of Brazil, CENIPA, and the press conference they held the same day. The briefing included an animation showing the last 3.5 minutes of the flight.
Every aspect with the preliminary report and animation is examined in detail, including a description of the ice protection systems and the stall warning system.
Links:
CENIPA - Preliminary report. dedalo.sti.fab...
Canal Vol - CENIPA press conference 6 September 2024. www.youtube.co...
ATR ice protection systems. • ATR ice & rain protect...
ATR ice evidence probe. • ATR 72 ice accretion, ...
American Eagle flight 4184. • American Eagle 4184: T...
Can you outclimb severe icing? • Can you outclimb sever...
Lift formula. • The lift formula expla...
#flywithmagnar #atraircraft #atr72 #atraccident #voepass #voepass2283 #aircraftspin #airlineaccident
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Muito obrigado🙇🏻 por compartilhar seus pensamentos sobre este acidente e esta tragédia.
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Peço desculpas se houver algum erro nesta (¿nessa🤔) tradução🙏🏼.
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Usei sites de tradução da Internet para traduzir do Hindi linguagem para o Português.
Thankyou for a great video. Their training seems to be very lacking.
@FlywithMagnar this comment is lost in the comment section. You might consider pinning it to the Top 😊. Also, you won’t find many Brazilians looking for this topic. We have a short memory and we’re currently busy with soccer (which isn’t a sport), shopping online and hiding from the women (who are cr4zy!) 😊
@@giork2828 As a Brazilian I can confirm people are actually interested in this, no clue what you are saying.
@@MrCaiobrz as a Brazilian, you should know most people forget a news topic or idol as soon as the TV stops talking about them. Very few people here have a hobby (entertainment ain't it), follow thru a story, or actually does some study on a topic of interest.
Magnar delivers. The most detailed, rational, and easy to understand breakdown of the events!
Yes oh yes - Blancolirio has been bested.
@@markmaki4460 You would expect detailed knowledge from an ATR type-rated instructor, but the presentation and the graphical elements are really what makes this video great to understand.
He also have a nice sense of humor.
The only part I found confusing is that it's not clear whether the de-icing is switched off or stops working. At the end he says that the orange "Fault" light is turned on when the system is on, and the animation does seem to confirm that. Either that's terrible design, or I'm missing something.
@@DrVictorVasconcelos The way I understood it was that the data shows if the switch is ON or OFF, but not if it was working. Earlier in the flight, the crew said that it was failed (seeing a FAULT light), which is how we know it was failed earlier. Then they switched it off and continued the flight. Later in the flight, the crew didn't say whether it was still failed, but repeatedly switched it on and off.
Although I haven’t flown for over 3 years (mandatory age 65 retirement), I still actively follow the industry, in particular the subjects of CRM, safety, and unfortunately accident investigations. Am familiar with the area, having flown various Boeing aircraft from the U.S. into Sao Paulo, but never flew any turboprops in my career, so I greatly appreciate the systems education. New subscriber to your channel. Thank you.
Exemplary breakdown of the preliminary report. A lot of factual answers, and the questions you raised at the end are relevant that needs to be addressed by the investigation. Thank you very much Magnar.
I fly a similar type, and can honestly say that this ice would have really got my attention!
My company’s procedure calls for a full 5 minutes after exiting icing conditions, and the crew being certain that no ice exists on the aircraft, before the anti icing and de icing systems can be switched off. We would have had the systems on for pretty much the entire flight!
Also, we bug our achieved cruise IAS in ice. 10knots of deterioration and we bomb out!
I feel certain that the ATC report of “traffic beneath” will be a significant factor!
The Preliminary Report shows also that at the moment, were the ATC gave the information to the Pilots that they would get clearance for descent, a B 737 MAX 8 of Gol was descending on 14000 feet straight across of the ATR into Sao Paulo while an A 321neo of Latam was just climbing out of Sao Paulo on the Three-O´Clock-Position of the ATR on 15000 feet. The ATR would have descended just onto the top of these two aircrafts, being at 17000 feet. Therefore the instruction of the ATR. The order to turn right should clear the ATR from both of these Aircrafts, what it would have done if the Aircraft wouldn´t have crashed.
But the ATC had no clue that the ATR was in a serious emergency situation because the pilots never told this to him.
Let alone ATC, from the report it seems like the crew themselves never realized they were in an emergency up until the full onset of the stall.
@@remigiochilaule1961 But after flying for more than 1hour in severe ice formation, and after all those system warnings, they should know that it was too risky.
@@brunomartinello1114 Exactly. The first action to prevent the accident would have been exiting icing conditions after the first Airframe De-icing fault.
@@remigiochilaule1961 Yes, very probably. I readed a comment in which it was mentioned that the FO short before the crash sequence of the flight started recognizing "a lot of ice". This commenter interpreted the call for descent as a reaction to this recognition. But probably they called the ATC only because they simply reached their top of descent and wanted to start the scheduled approach into Sao Paulo = the Captain had just started his usual approach briefing. So probably they had no understanding of how dangerous their situation had become - and this would raise the serious question: Why?
Damn, this really shows the swiss cheese in action:
- Forecasted severe icing, crew could have rejected to fly in such conditions
- Icing warning combined with a possibly faulty airframe deicing system, with forecast in mind - crew could have diverted
- Low cruise speed warning, confirmation or affirmation of icing situation
- Degraded Performance warning - crew did not keep icing bug + 30, crew could have descended, crew could have declared an emergency
- Increase speed warning - crew could have just followed the very clear instruction of increasing speed immediately
- If there was at any point any doubt about the reliability of the instruments, there should have been visible icing on the probe on the captain's side
- Stall warning - crew could have pushed nose down, wings level and followed a stall recovery procedure.
At this point, it is very obvious that the aircraft was performing as expected and to its certified limitations, but the flight crew did seemingly not react to any of the warnings signs. It will be interesting to see, what caused them to handle the situation as they did.
@@NeunEinser at this point it's not could, but should that is the appropriate term for those things they should have done at all those different stages of the flight
Excellent work, captain. This accident shocked me personally as I work in SBGR and VoePass ATRs they all park right in front of our office. Used to see PS-VPB daily. Keep up the good work!
Great analysis, Magnar, as usual. Best ATR channel on youtube no doubt.
Indeed.
Kudos to CENIPA that made such a complete and informative presentation on a preliminary report
Not a pilot, but a retired engineer of turbomachinery ( and flightsimmer ) ...what a precise and complete report about this accident and maybe the problems behind the scene . I am just admiring the way you design your videos. Unerreicht !
"Speed is life" well said Magnar. The more simple we make these crucial ideas the easier they are to recal in an emergency.
This is a very well constructed presentation. THANK YOU Capt.
Thank you Cpt for the effort to educate and present factual information to your viewers.
I fly in this ATR72 every week to work and from work in Australia.
Personally I like this aircraft.. doing job perfectly..
Bit of worry at that time of incident but I feel more calm now.
Thanks for sharing your knowledge that makes me more informed and understanding how this aircraft works.
Bit of worry? I would never sleep again
Instead of a maximum cruising altitude of 25,000 feet, the accident aircraft was dispatched with one of the two air conditioning packs operating, therefore, they were restricted to a maximum altitude of 17000 feet...
(One A/C pack is adequate to maintain pressurization as well as heat or cool this aircraft at 17,000 feet, as it has no drop-down supplemental oxygen masks for the passengers, hence, it is restricted by the amount of time required to descend to 10,000 feet, where there is adequate breathable oxygen available for the average human being…)
The only thing that they could do in this situation was to was descend to avoid the icing conditions, or not ever climb up into them…
Both the flight crew and the dispatcher dropped the ball in the process of planning the flight- there was a SIGMET for severe icing ON the route of flight AND AT the altitude (17000 feet) which the flight was planned and filed for... Then, the flight crew actually flew the airplane into the area of severe icing with a KNOWN De-Ice System "Fault", which had occurred early in the accident flight, which means that the system which removes ice from the leading edges of the wings and tail WAS NOT WORKING... At that point, they should have immediately descended to remain clear of the icing conditions, and if they could not descend enough to stay out of the ice due to high terrain along the route, they should have diverted to a suitable alternate airport or their point of departure, land, and have the De-Icing system problems FIXED…
Additionally, despite several aircraft warning system alerts telling the flight crew that the cruise speed was low, there was degraded performance, and warning them to INCREASE SPEED, they did nothing, and then initiated a turn to a new arrival fix... Almost immediately, due to the bank angle of the turn, and the large amount of ice on the aircraft, the aircraft stalled, then entered the unrecoverable spin which we have all seen in the pre-crash video footage...
While the end result of this accident only took a few short moments to occur, the lack of planning and attention to the very details which were the ingredients of the outcome were hours in the making, what is rather remarkable and stunning here is that the airline, dispatcher, maintenance and flight crew all had extensive experience in operating ATR aircraft, and HAD to know the long history of previous problems that this type of aircraft have had while operating in icing conditions, yet, they planned and operated this flight in such a casual, cavalier fashion...
I have several thousand hours of flying these ATR aircraft as a Captain, albeit many years ago when they were brand new, and was one of the first to experience the "exciting" flight characteristics of these machines while flying them in icing conditions, something, that despite all of the “fixes" to the aircraft and the operating procedures, continues to show its teeth and bite HARD when not treated with the utmost respect and caution…
Do you think that the plane, under the conditions it was in, should have continued flying at that altitude? Why do you think the pilots ignored the warnings about icing problems?
@@cgbryt I would speculate that the pilots had little experience with icing conditions. The climate is pretty hot in Brazil even in the winter. Unlike the northern hemisphere where pilots are dealing with snow all the time.
@@acasualviewer5861Also a proper winter or snow doesn't even usually mean that there is a lot of icing conditions as the colder weather leads to less moisture in the air in the first place.
I’ve got 3000 hours on the ATR. In this situation it would have not have been capable of flying at that altitude.
@@acasualviewer5861 There have already been at least two other accidents involving ATRs in icy conditions in Brazil. Pilots, who fly these planes, are trained to act in these situations. How could the pilots not know what to do?
The copilot had thousands of hours of ATR experience, the majority of his time as a pilot.
I am dumbfounded at why actions did not occur in the face of repeated and dire warnings.
Probably thought the warnings were false due to the fault light. Which doesn't explain why he didn't follow procedure and get out of the icing conditions at that point. In the end this will boil down to incompetence due to lack of icing training and/or negligence.
@@tuhkathri9126 They were trained! Other incidents and accidents on ATRs caused by ice have already occurred in Brazil. There are even RUclips channels depicting these accidents. This event occurred not the first time. There is no reason to believe the pilots were unaware of the dangers!
Wait so let me get this straight, they took a famously ice-vulnerable aircraft, with one pak inop which just so happens to be crucial for de-ice performance, and then fly it into severe icing conditions, while not keeping the de-ice on, and still after they get two very serious master caution alerts, they continue to fly normally and put the plane into a turn when it's flying in ice and more than 10knts under the icing bug? Am I missing something here? Jesus...
I agree with the points you have made but I disagree with the ATR series being more vulnerable to icing conditions than others.
@@marcg1686 How so? This is the 5th hull loss of an ATR 72 where icing was major contributing factor. American eagle 4184, Trans Asia 791, Aero Caribbean 883, UTair 120. And also in 2016, norweigian SAS4144 almost suffers the same fate but pilots recovered it. Between the sometimes rather inefficient boot system and the T tail design suffering icing in this plane can turn catastrophic very quickly.
Even though a PACK uses bleed air from the compressor section of the turbine, the loss of or deferral of one PACK does not affect the de-ice systems such as the boots on the wing and the tail. Technically, the loss of demand of bleed air, would if anything, help the airframe deice systems.
@@williambaker1136Yes I might have misconstrued that part. Thanks for pointing that out. It is strange that they kept turning de-ice off like it was malfunctioning no?
Also conca di crezzo accident in Italy @@frncbsino7164
ATR is a capable aircraft and sometimes you feel tempted flying beyond the limits of what is safe. Mix it with a company pressure and you have accidents like this happen.
I remember flying in really bad ice on ATR over Nowray but we always kept safety margins - because we knew that ATR can do funny things unexpectingly when at low speed +heavy ice.
In fact this particular ATR gave for over an hour multiple warnings before it started to do "funny things".
Would you be comfortable riding the ATR 72 as a passenger?
@@falconwaver due to the "Just in Time Operation Business Network" that involves Airlines, ATC, Airport Costs, and the Civilian Pilot itself that was reduced to a flight operator philosophy, we are not comfortable in any aircraft or company.
@@rocknrace9685you shot the center man! you win a beer... 😢
The ATR is not a particularly capable aircraft. You should never delay any corrective action with regard to its performance.
Yes. Once the preliminary report came out here in Brazil, everyone who flies or has flown the ATR realized what had happened on board. What a shame. The plane did its part perfectly.
vc diz que foi erro operacional?
@@xstavinhouu Treinamento/Cultura da empresa
@@xstavinhouu This part is what CENIPA will try to answer during the investigation.
@@MrCaiobrzEles foram treinados.
“Cultura” da empresa é o que?! Mandar os pilotos voarem em uma altitude perigosa com gelo severo e fazer de conta que os alarmes não estavam tocando? Colocar o avião nos limites sendo que já aconteceu algo semelhante que quase levou à queda de um outro ATR, no Brasil?
Até agora eu não me convenci de que o acidente aconteceu pq os pilotos não sabiam o que estava acontecendo. Se até os canais do YT já tinham comentado situações semelhantes, no passado, como os pilotos poderiam não saber?
Cansaço também não justifica. Um cansado ok. Mas os 2?!
Alguma coisa aconteceu para que ambos tenham ignorado todas as situações de risco. Se o problema foi a “cultura” da empresa, isso foi um crime
@@cgbryt Na história da aviação, a vasta maioria dos acidentes ocorreram por problemas de treinamento e cultura. Sim, a maioria. Só porque um piloto é treinado, não quer dizer nem que o treinamento era apropriado, nem que o estudante realmente absorveu o conhecimento. Já problemas de cultura são relativos a ou complacencia com situações raras, ou realmente uma empresa que força seus pilotos em situações menos que ideais. O piloto aceita, pensando que seu treinamento foi suficiente (pode não ter sido) e que ele vai fazer diferente em uma emergência, ou ele perde o emprego. Alguns dos acidentes envolvendo ATR por gelo foram devido à deficiência do treinamento em absorver o que se aprendeu com acidentes anteriores. Você deveria ler um pouco sobre acidentes antigos e como estão permeados de corrupção e atalhoes que acabam causando os pilotos não estarem preparados. O ser capitalismo das empresas sempre esta presente. Existem acidentes com causas assim desde o começo da aviação ... assim que a humanidade inventa algo, já tem algum capitalista para lucrar com isto à custa dos outros.
Thank you very much Captain Magnar for the excellent explanation.
Tried this in a sim after it happened. I'm not well versed on the atr but I noticed if I was distracted and hearing the same single chime through a flight on autopilot it was easy to miss them maybe degraded perf and increase speed should different chime and more alarming to the crew very sad prayers
You make a good point.
In the aftermath of the Helios Flight 522 crash, Boeing's use of the same aural chime for the cabin altitude warning and the take off configuration warning was put in question.
Absolutely. Aural chimes should have differentiating characteristics. Especially when immediate evasive action is essential to survival. Having said that they seem to have sleep walked into this situation.
@anthonyobrien3841 totally agree looking at the flt data the pilots time to respond to the ice warnings were gradually getting longer and with the attendant interrupting at the worst time
Great work Cpt Magnar, outstanding work….
Magnar competently presents the facts on the aircraft, crew, procedures and events and we the viewers watch how the plot develops towards a gruesome end. This is like the plot of a classic horror movie were the viewer hopes for the best of the protagonists knowing what the unavoidable end is going to be.
Another fantastic analysis Capt! I cannot believe these guys wouldn't exit icing when they got the icing fault...crazy
Beautiful breakdown of the preliminary report, clear and thorough!
Outstanding analysis. Thank you very much for this material.
Impressed by how you handled and relayed all the info. You have my full respect Mr. Nordal.
Oh, I waited for this video! Thanks Magnar
Thank you so much again for another amazing video on this accident. It’s a sad fact that the crew didn’t react to the icing condition, let’s now await the final report to get the answers.
I was waiting for this video ALL week
I, too.😃
Same here.
A very well presented explanation of the conditions encountered including very detailed explanations of the equipment making this a video that someone like me, who has no experience with the operations of an airplane, can understand. Thank you for the time you spent making this video.
Such a great video you made!! Thankyou!
Thank you for the video, Captain.
Thank You! for the very detailed analysis
As always, very clear explanation of what could have happened related the accident. I guess that the final report will concorde with your analisis. Saludos desde Buenos Aires.
This is top notch professional explanation!
I did learn a lot, so many missed chances to correct, very sad story.
Should have never happened.
So many red flags. So very sad. The ATR 72 is a great aircraft, but not designed to be flown like this.
Given the previous history of the aircraft type performing very poorly in icing, and several incidents of stalling before the shaker even activated, severe icing conditions are a NO GO situation. You simply can not fly the ATR in more than minor icing and must wait.
The best analisys I´ve seen so far about Voepass 2283 crash! Congrats and thank you.
Great analysis, Capt. Magnar. Many thanks!
The MEL indicates that they probably had the fuel to operate the flight at FL090/100 all the way. FL130/150 was all they needed to stay out of the severe icing conditions (with a TAT of 0C at FL170). Very sad.
Move to the head of the class, that’s literally what I was saying, after the first sign I going down to a altitude where my TAT is above 7 and that’s one less stress to worry about since fuel shouldn’t have been an issue for them
This is an excellent presentation of the systems involved and the facts from the preliminary investigation. Thanks.
PACK = Pressurization/Air Conditioning Kit. Good video. Thank you for the through presentation.
Magnar, you are an ATR God! I bet you could build an ATR from scratch with the level of knowledge and precision you have.
Training is a very strong tool. Don't blame the pilots. They did not understand the importance of all these indications. It means they did not understand the situation they were in. The PNF has the right to take the controls if the PF do not act correctly in a dangerous situation. But he didn't. Both wanted to complete the flight. But BOTH THEY DID NOT KNOW HOW TO DO IT.
Thanks. Training would be the key. I wish all ATRs had a direct hot-line to you in case of an emergency.
It is not a case of training… here. But I would rather inquire in company culture.
Thank you!
@richarddumont5389 I would say Training is very important. How common is severe icing in Brazil? Any meteorologists know?
@@oldmanc2According Brazilian pilots, it was a very uncommon condition in term of icing intensity. Many pilots flown the same route just before the ATR and took some photo of the accumulated icing in the windshield and the visual icing detector. They seem surprised.
Unbelievable! They didn't react to all those warnings. The investigation must focus on training and company culture.
They did react. They requested a descent that was denied due to traffic. They were flying in IMC. Possible collision would likely have been considered more of a threat than intermittent icing-related warnings. It's always easier to judge these things in perfect safety on the ground while already knowing what happens next. Different story when you're actually up there dealing with it. About the only thing they could do differently was declare a mayday and start a rapid descent but again, what good would that do if they thought they might hit another aircraft?
@@davidkavanagh189severe icing is an emergency, I’m ignoring ATC and descending, if the traffic was let’s say 1000 ft below even descending 500ft at a high rate could give you an extra 5-10 kts in this plane which would have prevented this, this is crew adequate inactions tbh
Indeed. It looks like as if this wasn´t only individual mistakes of these particular two pilots but that it is a more complex story.
@@davidkavanagh189They should have reduced their altitude much earlier... they were only going to reduce it because they were already arriving at their destination
@@davidkavanagh189 they requested descent not because of the icing, but because they have reached their top of descent and it's time to make way for the arrival. They were way too relaxed about the icing condition hence they were okay with the delay for descent clearance. If they were that concerned about the icing, they should have said, "need immediate descent due to icing", but they didn't say it. The controller didn't know they were in a condition between life and death.
Hard to blame the plane when it gave the pilots so many warnings. I have to question what purpose the pilots were serving in the cockpit? A pair of mannequins in the seats would have resulted in an identical outcome at lower cost to the company.
yeah it's unbelievable when you consider the fact they had almost 4000h of flight experience combined in that ATR 72
In the B-17 crash a few years ago I believe the pilots had over 30,000 hours combined, yet they made a series of pilot errors that combined in a lost airframe and all on board. Air time alone does not prevent accidents. It’s your CRM, decisions, mental attitudes, and airmanship THAT DAY that matters.
@@jamesw.123 Indeed.
The Errors of the Pilots were indeed so scary that they raise the question if this is a more complex story. No mentally healthy pilot would play voluntarily such a Russian Roulette. Because they did it there´re questions like: How was their training? Were they prepared for flying in such weather conditions? Why was an aircraft with an altitude limit of 17000 feet => so that it would stick right in the middle of the severe-icing-zone dispatched to fly this route? What´s about the Safety Management System of the Airline? When the pilots of an airline start to fail in such a way it should be detected by the SMS. Just to list these few.
AF447 would have flown much longer, and reached the continent with 2 mannequins in the cockpit. A lot of pilots today don't love actual flying but the status and lifestyle that comes with it.
Watching the indicated speed bleed off in severe icing conditions, and seeing that no action is taken by the crew, reminds me of Colgan Air 3407.
My conclusion from the prelim-report is:
1: The ATR72 is not at fault here. It does indeed have a history of issues regarding flight into known icing conditions, but this has been taken care of by updating the systems and POH accordingly.
2: Having confirmed now that the crew did NOTHING to take care of the developing situation, not even responding to the degrading airspeed, is disheartening to say the least, but again it is proof that the ATR72 itself cannot be blamed.
Was this due to lack of proper training from VoePass?
A very thorough and detailed walkthrough of this terrible accident. Very respectful, too. BR, Per (DK) Subscribed…
Hola Capitan, una excelente explicacion, un saludo especial desde Colombia
Hola soy inglés.
Viví en Colombia durante 4 años. Tengo amigos allí.
Es un país maravilloso con un paisaje fantástico y gente amable.
Tengo muchos recuerdos preciados de cuando viví allí. Espero volver algún día.
Saludos desde el Reino Unido.
👍😎🇬🇧🇨🇴
@@localbod Wow genial saber que viviste acá y que chevere que te haya gustado la amabilidad de nuestra gente. Un saludo cordial de un apasionado por la aviacion 😁
@@Jimenito1010 Muchas gracias señor.
Primero viví en un pequeño pueblo llamado San Antonio del Tequendama y luego me mudé a Bogotá después de un año.
Tuve la suerte de visitar Manizales y Nevado del Ruiz, Villa de Leyva, Agua de Dios, Girardot, Cartagena, Villavicencio, Choachí y Bucaramanga / Zapatoca. Conozco muy bien Mesitas de Colegio, La Mesa, Viota, Anapoima, Melgar, Carmen de Apicala, Fusagasuga y Bogotá.
Las mujeres colombianas son las mujeres más hermosas y apasionadas del mundo, pero también están locas. 😉
Estuve casado con una, pero ya no (larga historia).
@@localbod Conociste muchos lugares, que bien, yo paso vacaciones en Fusagasuga, es un lugar muy agradable.
Y con respecto a lo último, jaja es dificil imaginar que pasaría con la chica jaja.
@@Jimenito1010 Mi suegro vivió en Fusagasugá antes de morir. Es un buen lugar. Durante la Segunda Guerra Mundial hubo prisioneros de guerra alemanes que estuvieron retenidos en un hotel de la ciudad.
Mi ex esposa fue a visitar a una amiga suya (una chica colombiana de Bogotá que trabajaba ilegalmente) en los Estados Unidos. Habíamos acordado que ella estaría de visita durante 4 meses. Ella nunca regresó. Más tarde, me enteré de que ella comenzó a tener una aventura con un hombre de Puerto Rico, que estaba trabajando en el mismo lugar que mi ex esposa, solo 6 semanas después de que ella llegó a los EE. UU. Nos divorciamos en 2022.
Thanks Magnar. This debrief was simply outstanding.
Excellent explanation of the preliminary report very complete and you make questions to be solved in the final report. Great Job!!
Those pilots had plenty of experience. What led them not to take icing seriously as a threat?
O Captain voava o equipamento há 1 ano e meio e não tinha experiencia anterior como Captain em qualquer outra empresa que atuou. No máximo 700 horas de ATR
Metar at destination did not indicate icing. And sigmet issued after departure? but I don't know why ignore the indications.
my 9yo son has also "plenty of experience" flying a plane for his age, (mostly stright and level, and normal manoeuvring at standard turn rates and normal climb/descend. ) He is also very far from having good aerodynamic understanding, and I would not expect him to perform well in steep turns, icing, emergencies and single engine operations, simply because having experience in flying, does not mean I even tried to teach him all the other stuff. In this case I doubt the pilots ever got to learn the seriousness of icing, it is more like they were thought "if icing conditions, then press this button" -rather than actually understanding the effects of ice, or how it affects the actual stall speed. No number of flight hours of normal operation will compensate for insufficient training on abnormal situations.
@@foobarf8766If you’ve been flying IFR professionally you should know that IMC and near freezing temps always leave the door open for icing. I’m sure guessing they thought they could wait the 2 minutes to clear traffic before initiating the descent.
They took it seriously. They requested an descent and that was denied/delayed due to traffic.
Thanks for updating us Magnar, it is much appreciated. It is not looking good a good reflection of flight crew performance 😞🤔
Thankyou Magnar. I fly the ATR and have read the report - your video overlays it very nicely. We were just discussing the pilot actions while flying (in icing conditions) yesterday.
You should never see the DEGRADED PERF warning, to say nothing of an INCREASE SPEED alert. If it's gotten to that point, something is either seriously wrong with the aircraft -- or, as appears to be the case here, seriously wrong with the training.
For example, on the security of the internet, no one is allowed to talk about the real reasons and whether or not it really works.
But for sure we are 100% certain that essential measures have already been taken to further improve flight safety. "What was already safe will become even more so."
excellent rundown of the events, objective, factual, enlightening - as always.
The best video about the accident i ever see! Thank you! Greetings from Brazil!I'm a pilot too!
Thank you, Magnar, for your excellent presentation.
It's hard for me to understand how the situation deteriorated in the almost passive way it did in the face of a burgeoning EMERGENCY. I find the crew's reactions hard to understand, but I was not there.
I'll be waiting with great interest to see the final report.
As usual, fact based, clear and accurate information! Thanks from an airline pilot too 👍
Thank you for the excellent explanation
Excellent debrief
Thank you for this (and your other) videos. While I do have a bit of aviation knowledge, I‘m still just an „armchair pilot“, and as such I‘m always thankful for educational videos like yours. In this specific case, your video is a prime example of neutral and factual information without any attention-seeking or clickbaiting.
Keep up that great work, and while I already have been on a few ATR-flights within the canary islands and florida/bahamas, i hope to one day have the honour of enjoying a flight piloted by you in the maldives!
Greetings from Germany and happy landings to you!
Thanks for that wonderful and insightful review of the ATR procedures and what may have gone wrong in this instance. You certainly know the ATR inside out and backwards.
Excellent analysis and presentation. Thank you
Out of curiosity: Why are none of the performance advisories issued as "master warning" while signaling an impending loss of control? Maybe im missing something, but seems a bit odd to have an indication similar to an overspeed or stall event being accompanied with only a single chime?
The master warning in this instance would be the uncommanded autopilot disconnect, which could cause the aircraft to potentially lose control very quickly if the pilots doesn't grab the yoke immediately without delay. That is a higher level priority than the low performance warnings as you're given a little bit of time (from ~10 seconds to a minute) to think what you should do. If the low performance warnings trigger the master warning, the crew might find it a nuisance and when it goes off again for autopilot disconnect, the crew might not know WTF has happened. In other words master warnings require immediate, instinctive action, and low performance technically isn't, because you still have a few, to many seconds to think.
Imagine if another aircraft is below you and you get a master warning for increase speed. Your first action would likely be "OMG! Full power! Slam the nose down!", and you smash into the aircraft below. However if you get a master caution you would instead go "OK, master caution, low speed, OK lets increase speed here, full power, MCT on the knob, OK speed's not increasing here, let's descend now, OK nose down 1,000ft per minute, turn gently as well for a little bit of offset as there's traffic below, and uh hey bro can you please turn on all anti ice, give ATC a call for an emergency descent, and tell them we're turning left for a 5 mile offset for traffic. OK I'm off airway, let's increase descent to 2500ft per minute, speed's increasing past 190kts, I'll aim for 210kts, set altitude bug to 10,000, seatbelts on......".
Need to check the airlines Sim procedures and / or training standards
Indeed. It´s hard to believe that mentally sane Pilots would play such a Russian roulette with full knowledge.
Was waiting for you to cover this. Also can’t wait to see Blancolirio’s take.
Blancolirio isn´t an ATR training capain, he just reads out published info. So you can´t get better coverage than Magnar´s with respect to ATRs.
He is a 757 rated captain and GA pilot though so he certainly has a lot of experience, as does Magnar.
@xenadu02 Also 777, and if I don't recall incorrectly, 767 and A320.
Juan did cover this accident. Search for "ATR-72 Loss of Control"
@@VNAV_PTH 777
Very sad and unfortunate. It is especially unfortunate to lose the scientific/medical research team who were passengers on this plane and headed for meetings to discuss their findings. Condolences to all the family and friends of all those onboard. 🙏
Excellent video and thank you for the very thorough explanation of the systems.
I said it on another analysis of the report but I’ll say it again.
The fact that the pilots IGNORED all the warnings and seemingly ignored the weather warnings and never took decisive action to get out of that situation before it became an emergency is beyond sad and infuriating those guys had no business being at the commands of an aircraft without proper training for such conditions.
They were casually chatting until it was too late too.
Aviate Navigate Communicate in that order they failed on all three in this case and the consequences were catastrophic.
its crazy that the 60 year co-pilot event mentions "there's a lot of ice", because he can see it accumulated on the little probe near the cockpit windscreen which is supposed to mean that the plane is basically f**ked. I really don't understand how they were so casual and even confused when the plane went completely out of control.
I think it's easy to just blame the pilots, but as Magnar pointed out....they would only act in that manner if they did not have the proper training. So, what was their training like? And what was the company culture like?
@@danniballecter7936 No idea, but the ATR manual clearly states that severe icing demands immediate descent to escape such condition, and the plane did not fail on giving a bunch of warnings. Not saying they are the only ones to blame, definitely the company puts pressure and wants money, but this happens on every single job, i'm an engineer (I develop electrical cables), my projects and my work can put lives in risk, i will never put money over people lives because my boss or any superior told me to.
@@lucasmatsuoca and he had over 2500h or so flight hours in that ATR
They didn't ignore the warnings. They requested a descent and that was denied due to traffic.
I’m sorry for all the losses.
I’d like to know if ATR 42 / 72 computer or training is in need of update, icing related. A flight plan that enters above 20000 ft in an ATR is not normal, as far as I I know. But either way, the systems on the aircraft gave the pilots everything they needed in that scenario.
Congrats Magnar, you did a good job.
Excellent presentation. Thank you!
Wow, so they flew an aircraft with potentially INOP deicing into known severe icing conditions, then ignored the warning signs of coming trouble due to mundane operations and then forced the plane into flat spin. This real bad. The operational practices in this airline ... I can't even imagine what's hiding under the bad.
Dial back your mega assumption fest there pal. Where does the report say they intentionally dispatched with inop(potentially or otherwise) de-icing system?
@@davidkavanagh189 The report doesn't say anything like that and neither do I. I think you have mega assumption fest about my mega assumption fest, pal:)
It does say this though:
15:15:42 - a single chime was heard in the cockpit. Subsequently, the crew commented on the occurrence of an AIRFRAME DE-ICING Fault;
Obrigado Magnar pela analise detalhada e direta ao ponto, aqui no Brasil temos muitos "Peritos" em aviação que mais fazem alongar o assunto, realmente não entendo as tomadas de decisões mesmo com tantos sinais de alerta, certamente a muito que investigar ainda. Saudações aqui do Brasil!
Just Thank You!
Great job Sir Magnar , thanks a lot
I’ve flown 8 different jets in my 43 years career and only entered severe icing conditions once, in leveled flight at fl180. It was the scariest experience in my flying life. We usually passed through it during descent at very high speeds, eng anti ice on and once in a while wing anti ice. Don’t ever mess around in icing conditions.
I always said it. The plane itself wasn’t the one to blame. It was the procedures not followed by the crew that led to the crash.
Great. Thanks for your incredible insight. No need to do reports anymore now that we have you :)
@@davidkavanagh189 wdym ? I simply said what Magnar said ? 💀
That doesn't change the fact that the E175 fares much better in icing.
Suggestion for ATR operations:
Ice Detect sounds, all anti-ice systems turn on, increase speed and initiate descent.
You can only do so much for pilots determined to ignore every warning before automated systems are flying the plane instead of them.
Thank you capt. for these well expound prelim report video. subscriber from the philippines.
Dziękujemy.
Thank you Magnar for the crisp and clear report. Now we have to wait and hopefully find out if the pilots and/or pusher moved the controls towards a lower AOA, or not. And if yes, if the elevator can become ineffective in certain severe icing cases on this type, if you do not apply the procedures immediately.
Great video. Congratulations! 🇧🇷
The airplane did everything it could to warn the crew. The swiss cheese was only one layer that was the pilots. It is absolutely fair to blame the pilots. They had their heads up their ass.
@FlywithMagnar we have to consider the crew actions closely and point out this.
The first warning inflight was the Airframe de-icing fault.
You have mentioned several times that the system was reset and we don’t know if it was working - it should never have been reset and continued to be use and the flight continue in known icing conditions.
The procedure is direct and straight forward.
The QRH states for this failure to “leave and avoid icing conditions” as the first action and the turn off the system
At no point did the crew refer to the QRH or even discuss the system fault.
The action from the crew was wrong from the very first failure and this is critical to the accident. They continued to operate into known icing condition with an inoperative ice protection system not functioning and did not even acknowledge the effect of the degraded system further no regular visible inspection of the airframe was performed through out the flight.
We do not have the transcript from the CVR, so we do not know what the pilots said. Therefore, we don't know whether they read the checklist for airframe de-icing fault.
I live here in Brazil.
The accident site is near Guarulhos airport in São Paulo, where they were heading.
We have to wait for the final report to be released by CENIPA, but I believe that the pilots were not totally aware of the degrading speed. Yes, I know that the plane warned them a couple of times, but, maybe they didn't have full understanding of what was going on due to excessive workload because they were preparing to land in Guarulhos.
Anyways, they shoud have been aware of the degrading permance warning and a near stall. Unfortunately, both pilots did nothing to at least increase speed. But why? 🤷♂
It was either going to be cockpit chaos or complacency. In the end it was complacency and the autopilot was the icing on the cake. Thanks for your ideas and insights here and proves the autopilot was on in the lead up to the stall. Against all the rules in the book.
Icing and recovery failure, no surprise there. This was pure negligence, not an accident.
My brain is telling me there has to be a reason the crew did nothing but I don’t know what could explain the total inaction
In an Atr icing is so serious problem, you have to consider it like a fire, you really can't pospone or delay actions... 😮
@@extremehdsimulation5752
Ice accretion is a threat to any aircraft, not just the ATR series.
Good airmanship is what is required.
Sure it depends on aircraft.
But atr history shows a lot of accidents related to ice...
And stalls or loss of control at relative high speed for a turboprop.
Yes airmanship is 100% required, entering a severe ice predicted and actual zone with a faulty main de-ice system, and continue the flight, is a big no no.
@@rthraitorthe PF was communicating and the PM was communicating. It looks like lack of CRM. But we need to wait for the final report. For me, that flight should never fly an extra mile after the suspected malfunction of the de-icing system.
As always, great content. Keep it up
the sole video description is more than enough to qualify for "hard to believe"
I'm thinking if you hear those 3 chimes in a row and then the alarm, it would behoove you to take immediate action. Not trying to be flippant because it did result in a true tragedy.
I wonder if the airline uses EFBs mounted on the side windows.
Sometimes the placement of the EFB can obstruct the Captain’s view of the IEP which may lead to lack of appreciation of ice accumulated.
Excellent presentation!
Great report, for us in the aviation field, and the others that are not
Congratulations. Racional, but detailed. Direct. Easy to understand, even for people unsual in aviation.
Informative video!
thank you for this great and professionell explanation of the content of the preliminary report! 👍👍👍