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Last updated: 28 September 2021
Status:Final
Date:Monday 25 September 1995
Time:13:42 UTC
Type:Silhouette image of generic C208 model; specific model in this crash may look slightly different
Cessna 208B Grand Caravan
Operator:Brasil Central
Registration: PT-MEQ
MSN: 208B0414
First flight: 1994
Engines: 1 Pratt & Whitney Canada PT6A-114A
Crew:Fatalities: 2 / Occupants: 2
Passengers:Fatalities: 0 / Occupants: 0
Total:Fatalities: 2 / Occupants: 2
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:Gruenerwinkel Mountain, Guabiruba, SC (   Brazil)
Phase: En route (ENR)
Nature:Cargo
Departure airport:Navegantes-Itajaí Airport, SC (NVT/SBNF), Brazil
Destination airport:Blumenau Airport, SC (BNU/SSBL), Brazil
Narrative:
The crew took off from Florianopolis for Blumenau and Erexim in the Cessna 208, registration PT-MEP, carrying out a regular flight of cargo and passengers. At Blumenau there a change of aircraft was planned. Due to the weather conditions en route, the flight crew diverted to Navegantes.
Another aircraft from the same company landed at Blumenau and informed via radio that the weather conditions had improved. On the basis of this information changed aircraft to PT-MEQ, and departed for Blumenau.
The flight was performed below the proposed height of 1000 feet. The aircraft was seen flying between stratus layers, over Brusque and Guabiruba, in a valley on the left of the route to Blumenau.
The aircraft collided with a mountain.

Probable Cause:

Contributing factors
a. Human Factor
(1). Physiological Aspect - Undetermined
The flight schedule to which the crew members were being subjected at the time they were operating in the company was contrary to Law 7.183 of 1984 and may have led them to chronic fatigue and stress conditions.
(2). Psychological Aspect
(a) at organisational level - undetermined
There are indications that psychological variables at the organizational level, with respect to flight scale, training, standardization and procedures of the company and the flight group contributed to the accident.
(b) on an individual level - contributed
Throughout the operation, both crew members showed signs of anxiety, complacency, underestimation regarding the information received, motivation, change in perceptual synthesis, illusion and inattention.
b. Material Factor
There was no contribution from this factor.
c. Operational Factor
(1). Adverse Weather Conditions - Contributed
The cloud base and visibility conditions made it difficult to navigate and identify the control points on the ground, as well as making it impossible to see the obstacles.
(2). Disabled Panning - Contributed
Insufficient planning has led to crew members failing to navigate and fly themselves.
(3). Disabled Trial - Contributed
The failure of the crew to judge in relation to continued flight in adverse weather conditions and below the limits set by the Rules of the Air (IMA 100-12) contributed to the accident.
(4). Disabled Instruction - Undefined
There is evidence of the company's involvement in the investigation process, which did not give the crew the full technical conditions necessary for the flight to take place.
(5). Weak Cabin Coordination - Contributed
The failures committed on this flight indicate that at least one crew member failed to use the available navigation resources and the other failed to advise.
(6). Influence of the Environment - Contributed
There was an influence of the visibility and ceiling conditions, as well as the physical environment, in relation to the similarity between the valleys of the Itajaí River and Itajaí Mirim. There is also evidence that conditions in the administrative-operational environment of the company and the group of pilots contributed to the difficulties the pilots faced.
(7). Disabled Supervision - Contributed
The errors found imply failures of supervision in the flight schedule sector, with regard to compliance with the law, training and operations sector.
(8). Others - Contributed
The crew had little experience as pilots in the company and on the route flown.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Accident number: final report
Download report: Final report

Classification:
Insufficient rest / fatigue
Controlled Flight Into Terrain (CFIT) - Mountain

Sources:
» omunicipio.com.br


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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Navegantes-Itajaí Airport, SC to Blumenau Airport, SC as the crow flies is 44 km (27 miles).
Accident location: Global; accuracy within tens or hundreds of kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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