Fatal Aircraft Accident Investigation – Update

Given the tragic nature of VoePass Linhas Aéreas flight PTB2283, it is a fatal aircraft accident investigation of global importance. The Brazilian Aeronautical Accidents Investigation and Prevention Center (CENIPA) is investigating. CENIPA investigations are based on the international standard, namely ICAO Annex 13.

Both the Cockpit Voice Recorder (CVR) and the Flight Data Recorder (FDR) of the civil aircraft, registered PS-VPB, have been successfully replayed[1]. This is a task that required great care and diligence. The replay data now available to the investigators for detailed analysis, is of the utmost significance.

From the pictures available the external impact damage to the flight recorders is evident. What is important is that the crash protected memory module works as intended. This is solid-state digital memory that is packaged in a way that protects it from extreme conditions.

Finding from this accident investigation could have implications for the whole ATR aircraft fleet worldwide. It’s certain the authorities in Brazil will notify the aviation community if findings indicate corrective action that needs to be immediately taken.

Reports in the public domain indicate that the ATR aircraft had an ice detection system and that alerts could be heard in the cockpit during the flight[2]. Additionally, there is the indication that the crew acted in relation to those cockpit alerts.

[My apologies for a post where I suggested that there may not have been an ice detection sensor and alert on this class of turboprop aircraft. I was in error.].

This chain of events may suggest a simple set of explanations for the loss of control of the aircraft as it approached its destination. However, these matters are never simple, as most catastrophic aviation accidents are a combination of factors.

Even though the crew noted that there was icing, there is, as yet, no indication that the atmospheric conditions experienced by the aircraft in-flight were of a truly exceptional nature. The ATR aircraft is certified for specific icing conditions. There is training and procedures for the encounter of icing conditions.

It is pure speculation on my part, but I am reminded of an aviation accident of more than 40-years ago[3]. The conditions of the accident are different, but a factor may link the two. The last line of the NTSB report abstract says: “and the limited experience of the flight crew in jet transport winter conditions.” A small amount of ice contamination in the wrong place at the wrong time can have much more impact that might be immediately assumed.


[1] https://www2.fab.mil.br/cenipa/index.php/ultimas-noticias/1766-cenipa-extrai-com-exito-dados-dos-gravadores-de-voo-da-aeronave-ps-vpb

[2] https://www.flightglobal.com/safety/voepass-atr-crash-probe-analyses-crews-response-to-ice-alerts-before-fatal-flat-spin/159888.article

[3] https://www.ntsb.gov/news/press-releases/Pages/mr20220112b.aspx

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Author: johnwvincent

Our man in Southern England

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