Accident Beechcraft B200 King Air PR-DOC,
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ASN Wikibase Occurrence # 320894
 

Date:Saturday 28 July 2012
Time:07:45
Type:Silhouette image of generic BE20 model; specific model in this crash may look slightly different    
Beechcraft B200 King Air
Owner/operator:Vilma Alimentos
Registration: PR-DOC
MSN: BY-051
Year of manufacture:2009
Total airframe hrs:385 hours
Cycles:305 flights
Engine model:Pratt & Whitney Canada PT6A-52
Fatalities:Fatalities: 8 / Occupants: 8
Aircraft damage: Destroyed, written off
Category:Accident
Location:Juiz de Fora-Francisco de Assis Airport, MG (JDF) -   Brazil
Phase: Approach
Nature:Executive
Departure airport:Belo Horizonte-Pampulha Airport, MG (PLU/SBBH)
Destination airport:Juiz de Fora-Francisco de Assis Airport, MG (JDF/SBJF)
Investigating agency: CENIPA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
A Beechcraft B200 Super King Air, PR-DOC, was destroyed when it impacted trees, structures, and electrical power lines 245 meters prior to the landing threshold of runway 03 at Juiz de Fora-Francisco de Assis Airport, MG (JDF), Brazil. The foreign certificated pilots and 6 passengers received fatal injuries. The flight departed Belo Horizonte-Pampulha Airport, MG (PLU), Brazil.
Upon departure at 07:00 (10:00 UTC), the crew was not aware of the 09:20 UTC special weather report, with information that the weather conditions had deteriorated and were below the minima for IFR operations, with a ceiling of 400 ft.
This information was given when the crew contacted Juiz de Fora Radio at 07:30. Ceiling was now 100 ft. The crew decided to proceed and perform the runway 03 RNAV (GNSS) non-precision procedure. On the final approach, the aircraft collided with obstacles and then with the ground.
The President, Vice President and other executives of Vilma Alimentos, a Brazilian food company, were killed in the accident.

Individual information
a) Attitude - undetermined
The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.

Psychosocial information
a) Communication - undetermined
It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
b) Team dynamics - undetermined
It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.

Concerning the operation of the aircraft
a) Adverse meteorological conditions - a contributor
The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
b) Cockpit coordination - a contributor
The management of the available cockpit resources was not appropriate, resulting in failure of communication between the pilots, affecting the construction of the decision-making process.
c) Flight indiscipline - a contributor
The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
d) Piloting Judgment - a contributor
The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.

METAR:

09:00 UTC / 06:00 local time:
SBJF 280900Z METAR SBJF 280900Z 21002KT 5000 BR SCT005 SCT007 14/14 Q1023=

09:20 UTC / 06:20 local time:
SBJF 280920Z SPECI SBJF 280920Z 21003KT 2000 BR OVC004 14/14 Q1023=

Accident investigation:
cover
  
Investigating agency: CENIPA
Report number: A-004/CENIPA/2014
Status: Investigation completed
Duration: 1 year and 11 months
Download report: Final report

Sources:

G1

Location

Revision history:

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