I'm Brazilian, I have 3 pilots friends whom can't say in public what you said, but it's clear what happened. I agree with you and somebody has to blow the whistle.
what? why? is the headless mule gonna come after them? the curupira? herobrine? they dont WANT to say it, but they always could, you're not in venezuela anymore.
I heard audios on whatsapp from pilots talking about this hours after the tragedy. Basically, they know this since the beginning... they was just wanting to have shure there is no malfunction on the plane
"This isn't something you ask for; it's something you tell ATC you're doing." That is such an impactful statement, Stan. Pilots seem to forget about PIC authority when it matters most. It's almost as if the perceived fear of getting a call from the local FSDO outweighs what should be a fear/respect for worst-case outcomes. I've flown close enough, and through convective activity, I've encountered clear air turbulence once or twice, but I'm the most apprehensive of icing. I have no problem declaring an emergency or pulling the PIC card, upsetting ATC flow, or being the cause of any other subsequent inconvenience if it means I get to see my family for dinner.
@@LowandFast357 The fear may arise from the possible fact that according to an episode of the crash analysis tv series "Mayday" that the entire Brazilian airspace including ATC is controlled and manned by the military. Run afoul of the military anywhere, and those consequences may be severe. So the protocol there might be that military permission must be obtained first. And to just demand to, or just go ahead without permit, descend through multiple other flight levels could get one locked up. We in America live insulated from Military junta control. The rules in other airspaces are not necessarily the same as here.
@@jakerabinz9411I agree with what you’re saying but man that is just wrong if that’s really how they do things in Brazil. Saving 60 lives shouldn’t get you locked up for deviating in an emergency.
@@WalkrFilms Wrong or not, that is what military control " is what it is". Martial Law allows for the military to just come to your home, break down the door and haul you and your family off to some currently empty, but already prepared FEMA camp. No different than what China already has, and is populated with. The difference between here and there is the chinese populace are not armed. We still are. But the left wingers here including a cackling candidate with no deep heritage here is all about disarming the populace here. It is time wake up....
Well said. I took the report with a grain of salt, as they didn't show the full pilot-atc transcript... Not to mention CENIPA / Brazillian ATC are both managed by the military..
@@AdHominem888 For accidents, in this case, involving ATR aircraft, international bodies like France’s BEA also get involved since ATR is a French-Italian company. Regarding ATC transcripts, it’s common for many agencies like the NTSB or BEA not to release full transcripts, they focus only on key parts relevant to the investigation. CENIPA is serious.
I see your point. But as the report show, there is a long minutes on the transcript showing alarms buzzing and nothing been done by the crew... and as ATC is beeing questioning in this particular case, it would be safe to say, the full transcript in this particular case would be very much value, no?
Does the degraded performance sound the alarm? If that is a mayday shouldnt it? The objective of the report is to understand pilot reaction, we need to remember there are 2 pilots... If both are "wrong" something else is even wronger, in the airplane warning system or probably company culture, training, pressure. Thats why they have the final report... They want to understand the full context, rarely is just one person wrong... 😮
I think a lot depends on the safety culture and training at Voepass. If they were encouraged to fly in dangerous or marginal conditions the behaviour may have been normalised .
@@andrebello4191 no you don’t have to follow long checklist to get out of icing it is in the ATR training manual as a memory item not needing a checklist you also don’t need to speak to ATC in the event of an urgent or emergency situation
It’s easy to blame the pilots when you know nothing about training nor culture of the airline they were working for. I am an ATR pilot myself and my first thought after reading the preliminary report and their (in)actions was that they are in fault 100%, but then, thinking a bit outside the box led me to believe there might be something else.
@@NikitaKaminskyy culture? How about using common sense and exercising PIC authority. Sounds like you’re an FO in the ATR and not ready to take the left seat.
There is a strong assumption at NTSB that the crew was receiving unreliable airspeed indication. What this guy is doing in this video is unethical to say the least
@@ultimachamada1 If you're getting unreliable airspeed in those conditions, it may be the pitot tubes icing up.All the more reason to get out of the freezing altitudes. I think at 12,000 feet, there weren't icing conditions. It seems the crew didn't want to ask any 'favours' of ATC.. Foolish..
@@NikitaKaminskyy another thing I don't see mentioned enough is the accident was at 20-something latitude and the company went bankrupt, so shady dispatch of aircraft with INOP systems can't be ruled out, at that latitude icing is less a priority
I liked your style not covering up evident pilot errors like 99% aviation expert do. One more time, people die due pilot negligence. Here in Brazil, some stupid media were trying to blame the company and the aircraft model itself from day one.
Any kind of mistake in the aviation industry can be fatal. Forgetting something on a checklist can kill. A moment of loss of concentration can kill. Forgetting to tighten a bolt after maintenance can kill. A computer glitch in the flight software can kill. A moment of hesitation or indecision can kill. A pilot suffering from depression can kill. Sometimes I wonder if people forget just how dangerous it is to be suspended in the air tens of thousands of feet above the ground. It doesn’t matter how much experience you have or how skilled you are; every second that you’re flying could be your last. It’s terrifying.
I flew with Passaredo, a brief period on the Embraer 145 and then on the ATR fleet. I left the company in 2017 along with a group of other pilots, mainly because, in addition to other serious factors, we understood that it was only a matter of time before the company experienced a fatal incident. After the introduction of the ATR fleet and due to the various financial difficulties of the Felício family, everything was extremely borderline. We operated at the limit of everything! In 2016, there were 20 single-engine incidents in a fleet of 10 aircraft. PR-PDB, PDC, and PDH were always dispatched at the limit of MEL items. Takeoffs in aircraft PR-PDA, PDB, PDC, and PDI (the only 72-600s in the fleet at the time) were always critical because we had to reduce below the Takeoff Notch to avoid exceeding torque and temperature… A procedure so illegal that even ATR itself didn’t account for it. The then director of operations, along with a maintenance director, were removed from the company due to their “questionable” practices. So much so that PR-PDD almost had a fatal accident in Rondonópolis shortly afterward. I’ll bet my life, but Passaredo’s operational culture is largely responsible for the accident on 08/09. Watch the movie Whisky Romeo Zulu and you’ll see that Passaredo is and always has been a copy of LAPA, the Argentine company. Passaredo’s great asset is having a very good group of aviators, but unfortunately, they are still hostages to a disorganized, uncommitted company. ANAC should have revoked Passaredo’s CHETA at least 10 years ago; the agency is also largely to blame for all this.
@@Jorge-oh5ee It is the aircraft model itself that has a outstanding notorious glaring history of being a killer in icing conditions. Primarily because it has a very sharp kneepoint of going from stable flight to unrecoversble spin stall in a matter of seconds. Even the POH of the aircraft itself states that if altitude or airspeed suddenly goes negative, to IMMEDIATELY ESCAPE that environment. LIKE A PILOT CAN DO THAT BY JUST TOGGLING A SWITCH. WELL IT TAKES PRECIOUS TIME TO DO THAT. IT IS A PIECE OF SHIT DESIGN IN iMC.
*I would say 20% pilot error and 80% aircraft design.* 1. *You already know an aircraft is rubbish, when a pilot has to declaire PanPan or MayDay, and priority, emergency landing for a little bit of wing icing.* Thats just crazy. 2. As a pilot it is not easy to handle something that in 8,000 hours of flying, ends in an uncontrolable flat spin within 8 seconds. It comes as a shock out of nowhere. 3. The ATR 72 500 is an old plane that is good, cheap and reliable... but only for good weather, and *we need to start asking ourselves, if this aircraft should REALLY be flying passengers or only packeted cargo freight.* 🙄 4. *God bless the passengers and God have mercy on the pilots. AMEN!* 🙏
Being assertive and proactive as a Captain is a must if you want to live long and prosper. I would not have hesitated to declare an emergency and tell ATC to get the conflicting traffic out of the way because I’m descending, like it or not.
Great video Stan. Nicely produced with a great analysis on operating procedures, CRM and human factors. One of the best ones I’ve seen so far on this tragic and sad event.
The questionable decisions started on the ground. Dispatch flight planning into known severe icing and the pilots accepting it. Everything else was icing on the cake. Pilots need to learn to say, “No”. Simple Risk Management.
Provided all the ice protection systems are operational, The airplane is certified to fly in icing conditions, they couldnt say no on the ground. They could however, have said no to atc when they were denied a descent clearence. Be more incisive, declare a mayday and descend anyway, or even do a 180, anything but what they did.
@@rafaelrafoso it certainly does. All im sayin is that the pilots couldnt say no on the ground, having all the ice protection operational, the airplane is certified to fly in icing. Obviously pilots are trained to leave and avoid icing condition whenever possible.
Poor company cant handle canceling flights. They pressure pilots to never cancel flights. Pilots fly, survive once and then keep doong it with the idea the rules are too severe.
@@geraldo209 no aircraft certified before 2015 is certified to fly in severe icing no, particularly not a smaller turboprop with limited ice protection
Congratulations for being brave and speaking the truth, just the truth. There was a decisive human factor, a decisive mistake everybody avoids talking about. You're the first not doing so. If one can´t face the facts, can't make aviation safer either.
This is the most solid overview I've seen yet. Still terrible to watch. I used to be a mechanic on ATR72s before I was an airline pilot. Jumpseat on them a few times throughout Alaska.
Brazilian 737 driver here. Very well content and video. It is very unfortunate, but truth what you have said and shown. And i have to thank you for having the guts to do it and show it. Thank you. You got a new sub.
As a Dash-8 rated pilot, I disagree. The Dash series of aircraft is very reliable in adverse weather, including icing. The Dash 8 is used by all 3 major Canadian regional airlines, and the Dash 7 is even used by many northern operators in Canada, where icing is a year-long concern. I've personally flown the Dash-8 through several Canadian winters, and it handles icing quite well. Can't say the same for the ATR as I haven't flown it.
They are certified because both types have satisfied the requirements. Nearly 30 years maintenance experience on both types, trying to explain detection and protection in this system is more than a 5 minute conversation
Excellent presentation and information. You also provide very important points on operational discipline when it comes to flying airplanes. I was flying King Airs at the time of the Roselawn accident and several changes happened as a result. If I remember correctly, the FAA issued an AD related to flight in icing conditions for most Turboprop aircraft. If encountering severe icing, hand flying the airplane was part of the AD. It’s important to have the tactile feedback. I do remember that FSI added training scenarios in the Simulator. Regardless of aircraft type, if encountering severe icing take action to get out of it immediately.
Very good explanation. All those who comment on this accident avoid mentioning the rather obvious: the failure to continue the flight with an ATR in severe icing conditions.
The pilots continued in icing conditions for an hour after the deice equipment failure. There will be some other details in the final report, but nothing that will excuse that poor decision on their part.
Good job! Let's see how the Brazilian mainstream media will portray the information on this video. I'm Brazilian, and we usually are very sentimental and condescending.
Our ATR pilots diligently check the weather forecasts and delay or cancel the flight if known icing is predicted on their route. The APM system consists of accelerometers under the cabin floor, two TAT sensors, Ice Detector probe on the left wing. There is also an ice detector mounted on the fuselage left side window. This detector simply shows the Captain how much ice is accumulating. The engine inlets use inflatable boots as well. A faulty PACK does not have anything to do with the bleed air for the boots! This is a separate system.
He didn't say a faulty pack resulted in a boot fault. He said faulty pack, switched off for this flight, resulted in left engine delivering more thrust which resulted in right spin.
@@hndflights aircraft isn't faulty. None of the aircrafts flying is certified to fly in severe icing conditions and these are defined as conditions in which deice and anti ice systems may not be able to prevent/remove ice. Every pilot knows that you either don't fly inro severe icing conditions or if you find yourself in such, you get yourself out of there asap. These two seem to have been either unaware of danger they were in or disregarded procedures. ATR are very good aircrafts. Nearly all crashes in ATR were caused by pilot error
@@hndflights what you're saying is exactly waht happens with EVERY aircraft. You have a whole book of emergency procedures and in emergency one pilot flies the plane and the other follows checklist. Every aircraft has such procedures - boeing, airbus, dash, embraer. Just every. If the design was poor and dangerous as you say, the aircraft would not be flying.
The PF was the captain who had considerable less experience on the ATR than the PM. The captain never mentions the word "ice" during the entire flight even though the outside visual ice detector probe is only installed on his side ... On another note, there is a difference between flying into severe icing conditions and flying into KNOWN severe icing conditions. Root cause of this accident was a complete negligent and incompetent flight deck crew!
Condolences to the families and friends. Thank you 🙏 Sir for this educational video. May they rip Amen 🙏. Hi from Temple Terrace Florida. I’m a follower about airplanes accidents. 🇺🇸🇵🇷🇺🇸🇵🇷🙏🙏.
What do they drum into us from Day 1? AVIATE, navigate, communicate. Not just please ATC. Hate to imagine the screams in that cabin from helpless innocent passengers who deserved better.
Despite how challenging it is to instantly escape the danger zone, I’ve got to say, you did an amazing job breaking it down in this video! Your explanation makes it much clearer.
People always get sensitive when someone says that pilots make mistakes, acting like pilots are perfect, no, pilots make mistakes, guys, it is not unrespectful to tell the truth!
As a former ATR pilot, this is pretty dead on. It's astounding it stayed aloft as long as it did, so I gotta give Aerospatiale credit where it's due. However, my experiences on the ATR-42, and ATR-72-212(A) were less than stellar. As such, of the aircraft ive flown professionally over the past 17 years, the ATR is the only one I will never step foot on again.
It’s a safe aircraft when flown by a competent, well-trained crew who is willing to pay attention and get out of severe icing (or refuse to fly into it). Being prepared to exercise emergency authority if warranted (done it 3 times in the ATR) and to know and follow the procedures is the key. Every aircraft has its quirks. I personally don’t like to fly Airbuses but I know they can be flown safely.
The aircraft ATR 72 is certificate for flight in know Icing Conditions, but the difference in this case is they flew in SEVERE ICING CONDITIONS. In this condition is not certificate any Commercial Aircraft.
I think this is too forgiving to the company and it's too easy to blame pilots. Their biggest mistake was not saying 'no' to a contract that had them flying machines with critical systems INOP for over a year, if that is true.
Something we will never know is how used to this kind of warnings they were. Sometimes people go through warning so often and nothing serious happen that they start to ignore it and think it normal. "oh it's fine, don't overreact just because this ice warning or low speed, happens all the time" It's like when you do some shit on the road and it works and u start to feel confident enough to do it always. I have no idea if this is the case, but I wonder if it can help to explain their lack of matter for all these signs
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If we were to analyze all accidents as simply human causes, we would not get to the real causes. The actions of the pilots are all the result of the work of the companies, manufacturers and regulatory agencies. Therefore, all human errors are actually systemic fault. If the factors that led to these errors are not corrected, the risk of other accidents of this type will continue to exist.
Max power and pitch down for a spin recovery?? Is that aircraft type specific and if so, does that suggest this aircraft was spun in test flights? Thanks for sharing.
when in icing conditions , if de-icing fails ... get out of the icing zone asap & increase speed ? one really needs to browse a manual for the obvious ?
Excellent and clear video as always. Only thing, the reference to “around the equator” at 08:02 seems to imply that São Paulo is not too far from the equator, whereas in fact is very far from it. As a matter of fact, Mexico City (19°25’N) is closer to the equator than São Paulo, that lies at 23°32’S, only one degree LAT farther from the equator than Key West (FL), that is 24°33′N
An excellent analysis of the flight and the unfortunate crash. Although I haven't flown as a pilot in many years, I learned over 50 years ago that when in a questionable situation, "Aviate, Navigate, Communicate." I could not agree more with the need for the pilots to commence an immediate descent to lower altitude and to inform ATC that you are doing so. Not ask for permission. A Pan, Pan, Pan would have been appropriate. Flat spins in aircraft with a high mounted horizontal stabilizer can be a chore to control the aerodynamic characteristics that a flat spin poses to that type of aircraft. Nose down, immediately increase airspeed to make certain the horizontal stabilizer has enough aerodynamic energy and airflow to give the aircraft pitch control in the vertical axis and the added ability to stop the spin. Unfortunately, this accident happened, and my condolences to the passengers and flight crew.
Why? Why would you turn off the airframe deice though? That seems counterintuitive to being in heavy icing conditions. And doing nothing as it pertains to the "hold at seventeen thousand feet" when you are loaded with ice seems insane?
Agree with Geraldo + some of the boot sections could have been working and one (or others) not. Asymmetric de icing is worse than no de icing and could have contributed to the spin.
The Finns and Swedes use the atr 72 in the middle of winter and there has never been a problem with icing. Some companies should take two or three training courses in the countries mentioned above.
*I would say 20% pilot error and 80% aircraft design.* 1. *You already know an aircraft is rubbish, when a pilot has to declaire PanPan or MayDay, and priority, emergency landing for a little bit of wing icing.* Thats just crazy. 2. As a pilot it is not easy to handle something that in 8,000 hours of flying, ends in an uncontrolable flat spin within 8 seconds. It comes as a shock out of nowhere. 3. The ATR 72 500 is an old plane that is good, cheap and reliable... but only for good weather, and *we need to start asking ourselves, if this aircraft should REALLY be flying passengers or only packeted cargo freight.* 🙄 4. *God bless the passengers and God have mercy on the pilots. AMEN!* 🙏
"2. As a pilot it is not easy to handle something that in 8,000 hours of flying, ends in an uncontrolable flat spin within 8 seconds. It comes as a shock out of nowhere. " So... what about ignoring the problem multiple times? Is that an aircraft design problem?
@@livestock9722Educate yourself 1. The ATR has had 67 accidents, resulting in hull losses and 530 dead people. 2. This year in 2o24 alone, there have been 8 accidents with the ATR 72 aircraft. 3. Most of these problems are with the deicing rig. 4. The job of a deicing machine is to deice and not to 6 false alarms when its working and 8 false alarms when its not working.
@@focusaddiction3460I can see you have not a clue what you are talking about. You would have NOT known what to do in this case if you were in there as you have zero training.
@@AgonxOC Well, you say "you have no clue what you're talking about", and i think "i know what 'low speed' means". As long as you know english you should know what to do when the message low speed appears. It's like if we had a monitor for our heart and the monitor said "heart attack!", i'd know i had to run to the doctor. But if you think i don't know what i'm talking about, please tell me what you do when a plane tells you that you're in low speed, should go slower? I'm curious now
Excellent synopsis, Stan. As another commenter stated, thanks for not insultingly deflecting the responsibility of this incident off of those pilots. Which is a faux pas amongst many self back patting pilots, who will continually blame the ATR-72. Regardless of reality.
50% pilot error, 50% risky/outdated plane design (don’t defend problematic designs - having to declare a mayday for severe icing regularly as a part of SOP sounds insane and is a disaster waiting to happen)
Nope. It’s ALL Pilot error. That plane was certified for FIKI. They stayed in it and ignored the warnings INCLUDING their training on icing. The plane did what it was designed to do. The pilots pushed it beyond its limitations. There’s ZERO argument about that.
@@c208driver6being certified to fly in icing conditions doesn't mean the airplane is ice proof. The result of an ATR flying into severe icing condition with some malfunctions spoke for itself, and it was not the first, second or third time. This type of airplane has a history of many similar incidents and crashes. This crew believed they were doing the best they could, but unfortunately it was not enough If I had a relative who was as a passenger in that crash , I would be deeply in pain. If I were the father / son of any of the involved pilots, I would be even more in pain, specially after such unnecessary remarks raised by this video
@@pedrohmu OK. So I have A LOT of experience flying in icing conditions. So I know what I am talking about. The plane was certified and the pilots were or SHOULD have been trained to understand the limitations of flight into icing conditions in that SPECIFIC airplane. There is no airplane that is certified to fly into CONTINUOUS icing and that is EXACTLY what this crew did KNOWINGLY. Even after they encountered icing and the equipment failed, they took NO ACTION to exit icing conditions which ALL pilots are required to do when there is either a failure of the equipment or the ice is overwhelming the system. What they did was criminal. It was 100% their fault based on the facts of the case. They entered icing conditions, had an equipment failure and then proceeded to continue to fly into it for an extended period of time in an airplane that has a history of not doing well in icing. There were even reports of severe icing, so it's not like they didn't know what they were getting into. Icing is probably the most dangerous type of hazard in aviation. From experience, sometimes you have less than one minute to take action before it's too late. It's pilots that make the decision to stay in ice instead of exiting immediately that end up killing a bunch of people. Furthermore, anti-ice/deice equipment is designed to give you time to exit the icing conditions when you encounter them, NOT to continuously fly in it. Especially when the equipment fails. So 100% their fault. If they would simply have climbed or descended they could have gotten out of the situation. But they didn't and the result was a bunch of people getting killed. it's clear you don't know what you're talking about
The Pack inop did not interfere with ice protection systems. Provided all the ice protection was operational, the airplane can be dispatched into icing conditions because it is certified to. The crew however should have left icing conditions the moment they got that fault light though.
@@encinobalboaice can form on FL240 too depending on how bad the cold front youre flying in is. Fact is pack inop does not hinder the ice protection systems inop. Once they got that airframce deice fault light, thats a no go for sure, and they should have descended to fl100 or even lower. And it wouldnt matter to their fuel consumption anyway. Very sad.
the SIGMET said there was SEVERE ICE in that route and altitude, severe ice is an emergency as the ATR manual says, so is it right that the plane was dispached into severe ice? even with deice working?
The ATR is not safe in icing period. It is an efficient turbo prop. Aerodynamically it is great and the HORIZONTAL tail is sized to be optimal. In ICE it is not sufficient. The ANTI ICE system and design is marginal. That tail should be bigger and NOT A T-TAIL. There has been many twin turbo prop airliner accidents realtered to ice, ATR being the leader in ice related accidents, To be fair, turbo props spend a lot of time in lower mid levels where ice is an issue. Jets in the mid 30's are not in ice conditions, and they climb and descend fast through lower level altitudes. I was offered a job to fly ATR as Captain for cargo. I almost took the job but kind of glad I passed.
I’m not sure what your issue is with T tail turbo prop aircraft, I’d assume you have an engineering degree along with you ATPL . If you ignore and advisory of severe ice and make failed attempt to mitigate and avoid , you can never blame an aircraft. I’ve spent nearly 30 years in aircraft maintenance and I’ve dealt with many whiny pilots that sound just like you .
I agree with Duncan. You missed a golden opportunity to increase your skills. I flew the ATR for 8.5 years before the RJ and look back fondly at that time. Yes I flew it in icing conditions and even encountered severe icing 3 times. It was a safe plane when you complied with the procedures or rerouted or delayed when the ice was going to be bad. Hopefully, you flew something besides an RJ before going to a major? Those folks and single seat fighter only pilots take the longest to become seasoned at the majors.
It wasn't a secret they would incur icing conditions on this flight. The problem is complacency as they were able to skirt by before. The last 2 minutes of this "flight" must've been unimagimably horrific.
Good talk. One pedantic note: Airliners haven't had steam gauges in 60 years. The round dials pre EFIS found in an airliner cockpit were absolutely electronic devices...analog electromechanical stuff with analog computing for various functions. Quite different than the true steam stuff in a vintage GA plane.
@@wgmskiing That really made me laugh. 60 years earlier from 2024, was 1964. While transistors were found in pocket radios. "Computers" were still IBM punch cards, feeding into a room full of Eniacs or Univacs. The 8O88 microprocessor was still more than a decade a away. Obviously you are someone that knows nothing of tech history at all. In the Boeing 707, state of the art in 1964, there does not exist any glass in the cockpit displays at all. The only glass is in the windshields, and the faces of the so called. "steam guages". I know, because I was actually alive back then. You obviously did notveven exist.
@@jakerabinz9411 I can't speak to the 707, but I can with some authority talk of the 727 because I have a project involving it on my desk right now. It first flew in 1963, and every one of the "steam gauges" was electronic. The air data computer was an analog electronic device. The auto flight system included discrete logic for gain programming and gating different modes. The altimeter, attitude indicator, HSI, airspeed indicator....all electronic devices and most included significant numbers of discrete transistors. A Cessna 172 of that era came with steam gauges, nothing but vacuum gyros and pito/static driven bourdon tubes.
How is it legal to fly with one pack defective? Wouldn't it be extremely dangerous if the second pack broke during flight resulting in no fresh air in the cabin?
There are ram air scoops to deliver fresh air if needed. The aircraft would slowly depressurize if the second pack failed but between descending and oxygen masks everyone would be okay.
@@flyingformoney777Thank you for your reply and answer. No air flow would lead to CO2 build up in the cabin. The brain chemoreceptors will start giving you that feeling of suffocation due to CO2 build up long before O2 drops enough to fall unconscious. Do you mean the ram air scoops work passively and independently of the packs?
@@themilkman7367 yes. They are often used to cool the pack heat exchangers (I.e. air conditioning the hot bleed air from the engines) but can be rerouted to supply fresh outside air into the aircraft.
@@flyingformoney777 Thank you for this information. It has always been a point of anxiety for myself, thinking that, should the packs go down, you're stuck in a sealed metal tube with who knows how many people exhaling co2. In physiology course, I was picked for the rebreather test. It consisted of a bag with 10 litres of pure oxygen connected to a device to measure breathing that you stuck in your mouth. I can only describe it as gradual horror as the co2 climbed giving the feeling asphyxiation despite there being more than enough oxygen. Horrific.
I think in most general aviation aircraft. The recovery for spin procedure is actually to reduce power to idle first. The thrust and prop stream actually interfere with the recovery for a few different reasons. Then you neutralize the ailerons. Then you use the rudder opposite to get out of the spin. Then pull out of the dive. Then add the power. This is a flat spin though things might be different. Its a bigger plane too.
I think when I started flying Cessna that was the protocol for a stall induced spin( power on stall) I’m not sure about a flat spin-I think most aircraft are not certified for flat spin
Multiengine airplane pilots would be very hard pressed to recover from a spin, because of the large moment of rotation from the engine mass, far away from the center of rotation. Very much more so in transport category airplanes, let alone in a flat spin where airflow around control surfaces is all over the place.
@@coriscotupi yes I’ve never flown any transport category aircraft and only flown light twins under instruction but I know that I don’t think there’s any transport aircraft rated for spinning for that reason
The deicing system repeatedly turning on and off was likely due to a malfunction, with the pilots making several attempts to keep it running (possibly because the system never fully activated). Repeating the process might eventually cause it to stay on.
🇧🇷here good video Well explained, here in Brazil the situation is not very good with the Twitter ban, I practically don't know any news, I'm just going through life blindly and find out about updates through your very well explained video
The investigation into this accident is still ongoing and there are still many things to be determined. Only a preliminary report has been released detailing the situation. However, it is still too early to make statements as if the case has already been solved. It is also necessary to have a little respect, including for the families of the crew members.
Nice video. 2 points, though: - using mostly the -600 cockpit sim for this video is somewhat misleading. - there is no spin recovery procedure for transport aircraft like the ATR, especially not for a flat spin, which is likely not recoverable.
I was afraid this was the cause of the crash. Again the series of events that were left unattended getting you into trouble. Also twins once in a spin are very hard to get out of a spin if not near impossible--- sadly game over for them once spin initiated. Thanks for a thorough and clear breakdown of this accident.
In a serious incident with an ATR-72-212 of TRIP Linhas Aéreas in a night flight in 2013, the aircraft enter in ice formation area - under autopilot control; the pilots activate anti-ice devices, but not the de-icing devices for wings and engine naceles, suffer speed reduction, stall and fall. The pilots don't follow the aircraft manual procedures: - The PIC fight against the stick pusher. Manual instruct lower the nose. - The SIC ask if PIC want he turn of engines, have no response, so he feathered the propellers. Manual instruct set 100%. Anyway the plane level at FL110 - after fall 5000 feet; and land safety in destination.
As the name says, this is a preliminary report. Also, you can see on the report that the request to descend was a "top of descent", not a request because of icing. But most important, even if the final report points several contributing factors about the pilots, you should remember that they also lost their lives. Their families and friends have to deal with the grief and also see the faces of their loved ones being used in thumbnails like the one in this video. You can talk about the facts and be respectful at the same time. Look at the channel "Aviões e Músicas". It is from Brazil. The guy is respected in his field, has millions of subscribers, makes a lot of money, and you'll never see him pointing his finger in cases like this.
It's relevant to say that this airplane got only 1 pack operational, causing to trigger the airframe de ice fault... and of course to say... That the fault was not only by the crew, but also the ATC AND Airline itself. Airline put "some" Pressure on pilots for take off no matter what, (you can find footage of VoePass taking off in a middle of a major thunderstom, with windshear resulting in almost a disaster shortly after the take off), pressure to not declare emergency (in Brazil all panpan and maydays are investigated after the aircraft land, and punishment "applied"), pressure on pilots to not go around due to more fuel usage and aways take off with sometimes... enough fuel just for alternate, or even just for one go around, no extra fuel for holds etc etc. This aircraft had a tailstrike months before the day of accident, airframe repairs was done, and was forced to take off without landing gear operational (Extended), this aircraft in the day of tail strike flight; failed completely the right wing anti ice boots, and the left half operational... And also the company lack of "trainement" (again increasing the workload on the pilots), in ice conditions. This airplane was an ice brick, they did it before... hot summer, descending the ice ll just melt and good to go. (In their minds... They did several times... Whats wrong to do it again?) With this lack of awareness, and pressure by the company... MAYBE, the pilots didnt understood the BIG problem they were facing and, not even the emergency checklist was possibly conducted. The ATC cleared them for a right turn for an initial fix, prior to execute the SBGR STAR, but to STAY at FL170... they replied, and with a big "THANKS" in the final reply, did the turn... and almost imediately the flying ice brick... stalled. On my company several pilots fly this kind of equipment... in the same situation +50 knots of present speed, in the moment of the first ice alert... ALL DE ICE and ANTI ICE ON... and IF the Alert insists... mayday mayday mayday, nose down, prop 100%, engine 100%, a bit of overspeed flying STRAIGHT until the ice melt. Sadly, its not only a pilot factor here... but begins, with the company... going thru the pilots, AND THE ATC. Im speechless with preliminar reports... with 737-700, facing severe ice between 160 and 250... when entering below 250... we just REFUSE to turn, following the STAR path, 99% of the times the ATC got pissed of... we just answer back "SCREW YOU, LACK OF PERFORMANCE, WE LL MAINTAIN HEADING" and he clear the path ahead. This simple. But... Why Im speechless... They not only followed the ATC instructions... and said "THANKS" but also REDUCED the IAS to 169 knots... Oh God have mercy and RIP to all souls on board.
Say they made a mistake or they were negligent with correct procedure is what midia is doing. Human factor is part of every accident, the difference is knowing WHY they didn’t what they should have done. Everyone that flies in airliner is thinking why there were so many warning and none reaction, but the essential will be discover WHY, not just know they didn’t.
Airline culture, training, SOP, CRM, AFM, FOM, line culture, line checks, hiring practices, cockpit discipline, upgrade requirements, pilot history need a good look. The known facts point to human factors.
Being certified to fly in icing conditions doesn't mean the airplane is ice proof. The result of an ATR flying into severe icing condition with some malfunctions spoke for itself, and it was not the first, second or third time. This type of airplane has a history of many similar incidents and crashes. This crew believed they were doing the best they could, but unfortunately it was not enough If I had a relative who was as a passenger in that crash, I would be deeply in pain. If I were the father / son of any of the involved pilots, I would be even more in pain, specially after watching a video and comments full of overly unnecessary remarks.
But you are none of those people, and yet you are offended. As far as being a pilot goes, I am hard on myself too. I truly feel for the sufferings of the loved ones, but I’m more concerned with emphasizing to other pilots the errors that were committed here in order to save future families from going through what these families are going through.
@@flyingformoney777 It's true. I'm not one of them, but it doesn't mean I can't put my self on their shoes. As a pilot, I believe that the concepts of leadership don't give me the right to act hard because it would brake the communication chain with the crew, and I am the final one who most need to receive the best communication and the best preformace from the crew. This is only achievable on a good created environment. Statistically, any crew member, including me and you, make at least 5 minor mistakes during any flight. So in my opinion, being too hard or either too soft is undesirable, specially when dealing with thousands of lives each month.
I'm Brazilian, I have 3 pilots friends whom can't say in public what you said, but it's clear what happened. I agree with you and somebody has to blow the whistle.
what? why? is the headless mule gonna come after them? the curupira? herobrine? they dont WANT to say it, but they always could, you're not in venezuela anymore.
I heard audios on whatsapp from pilots talking about this hours after the tragedy. Basically, they know this since the beginning... they was just wanting to have shure there is no malfunction on the plane
Pois é
"This isn't something you ask for; it's something you tell ATC you're doing." That is such an impactful statement, Stan. Pilots seem to forget about PIC authority when it matters most. It's almost as if the perceived fear of getting a call from the local FSDO outweighs what should be a fear/respect for worst-case outcomes.
I've flown close enough, and through convective activity, I've encountered clear air turbulence once or twice, but I'm the most apprehensive of icing. I have no problem declaring an emergency or pulling the PIC card, upsetting ATC flow, or being the cause of any other subsequent inconvenience if it means I get to see my family for dinner.
@@LowandFast357 The fear may arise from the possible fact that according to an episode of the crash analysis tv series "Mayday" that the entire Brazilian airspace including ATC is controlled and manned by the military. Run afoul of the military anywhere, and those consequences may be severe. So the protocol there might be that military permission must be obtained first. And to just demand to, or just go ahead without permit, descend through multiple other flight levels could get one locked up. We in America live insulated from Military junta control. The rules in other airspaces are not necessarily the same as here.
@@jakerabinz9411I agree with what you’re saying but man that is just wrong if that’s really how they do things in Brazil. Saving 60 lives shouldn’t get you locked up for deviating in an emergency.
@@WalkrFilms Wrong or not, that is what military control " is what it is". Martial Law allows for the military to just come to your home, break down the door and haul you and your family off to some currently empty, but already prepared FEMA camp. No different than what China already has, and is populated with. The difference between here and there is the chinese populace are not armed. We still are. But the left wingers here including a cackling candidate with no deep heritage here is all about disarming the populace here. It is time wake up....
I took from the report that the request to descend was a normal “ top of descent “ request , rather than a request because of ice .
Well said. I took the report with a grain of salt, as they didn't show the full pilot-atc transcript... Not to mention CENIPA / Brazillian ATC are both managed by the military..
@@AdHominem888 For accidents, in this case, involving ATR aircraft, international bodies like France’s BEA also get involved since ATR is a French-Italian company. Regarding ATC transcripts, it’s common for many agencies like the NTSB or BEA not to release full transcripts, they focus only on key parts relevant to the investigation. CENIPA is serious.
I see your point. But as the report show, there is a long minutes on the transcript showing alarms buzzing and nothing been done by the crew... and as ATC is beeing questioning in this particular case, it would be safe to say, the full transcript in this particular case would be very much value, no?
I mean, the NTSB it self was put on around 60/70 bc full transparent was necessary.
Does the degraded performance sound the alarm? If that is a mayday shouldnt it? The objective of the report is to understand pilot reaction, we need to remember there are 2 pilots... If both are "wrong" something else is even wronger, in the airplane warning system or probably company culture, training, pressure. Thats why they have the final report... They want to understand the full context, rarely is just one person wrong... 😮
Why is it so frickin complicated to immediately get out of the danger zone?
I think a lot depends on the safety culture and training at Voepass. If they were encouraged to fly in dangerous or marginal conditions the behaviour may have been normalised .
Sometimes its because they have to follow long checklists. And get clearance from ATC
It seems s like pilots forget the skill of flying their aircraft and what keeps it aloft.
@@andrebello4191 no you don’t have to follow long checklist to get out of icing it is in the ATR training manual as a memory item not needing a checklist you also don’t need to speak to ATC in the event of an urgent or emergency situation
pilots are afraid to be punished by ATC/company
It’s easy to blame the pilots when you know nothing about training nor culture of the airline they were working for. I am an ATR pilot myself and my first thought after reading the preliminary report and their (in)actions was that they are in fault 100%, but then, thinking a bit outside the box led me to believe there might be something else.
@@NikitaKaminskyy culture? How about using common sense and exercising PIC authority. Sounds like you’re an FO in the ATR and not ready to take the left seat.
@@c208driver6 Culture shouldn't come into professional flying.
There is a strong assumption at NTSB that the crew was receiving unreliable airspeed indication. What this guy is doing in this video is unethical to say the least
@@ultimachamada1 If you're getting unreliable airspeed in those conditions, it may be the pitot tubes icing up.All the more reason to get out of the freezing altitudes. I think at 12,000 feet, there weren't icing conditions. It seems the crew didn't want to ask any 'favours' of ATC.. Foolish..
@@NikitaKaminskyy another thing I don't see mentioned enough is the accident was at 20-something latitude and the company went bankrupt, so shady dispatch of aircraft with INOP systems can't be ruled out, at that latitude icing is less a priority
Thanks Stan. Good content as usual.
Very welcome
I liked your style not covering up evident pilot errors like 99% aviation expert do. One more time, people die due pilot negligence. Here in Brazil, some stupid media were trying to blame the company and the aircraft model itself from day one.
GloboLixo
Any kind of mistake in the aviation industry can be fatal. Forgetting something on a checklist can kill. A moment of loss of concentration can kill. Forgetting to tighten a bolt after maintenance can kill. A computer glitch in the flight software can kill. A moment of hesitation or indecision can kill. A pilot suffering from depression can kill.
Sometimes I wonder if people forget just how dangerous it is to be suspended in the air tens of thousands of feet above the ground.
It doesn’t matter how much experience you have or how skilled you are; every second that you’re flying could be your last. It’s terrifying.
I flew with Passaredo, a brief period on the Embraer 145 and then on the ATR fleet. I left the company in 2017 along with a group of other pilots, mainly because, in addition to other serious factors, we understood that it was only a matter of time before the company experienced a fatal incident. After the introduction of the ATR fleet and due to the various financial difficulties of the Felício family, everything was extremely borderline. We operated at the limit of everything! In 2016, there were 20 single-engine incidents in a fleet of 10 aircraft. PR-PDB, PDC, and PDH were always dispatched at the limit of MEL items. Takeoffs in aircraft PR-PDA, PDB, PDC, and PDI (the only 72-600s in the fleet at the time) were always critical because we had to reduce below the Takeoff Notch to avoid exceeding torque and temperature… A procedure so illegal that even ATR itself didn’t account for it. The then director of operations, along with a maintenance director, were removed from the company due to their “questionable” practices. So much so that PR-PDD almost had a fatal accident in Rondonópolis shortly afterward. I’ll bet my life, but Passaredo’s operational culture is largely responsible for the accident on 08/09. Watch the movie Whisky Romeo Zulu and you’ll see that Passaredo is and always has been a copy of LAPA, the Argentine company. Passaredo’s great asset is having a very good group of aviators, but unfortunately, they are still hostages to a disorganized, uncommitted company. ANAC should have revoked Passaredo’s CHETA at least 10 years ago; the agency is also largely to blame for all this.
@@Jorge-oh5ee It is the aircraft model itself that has a outstanding notorious glaring history of being a killer in icing conditions. Primarily because it has a very sharp kneepoint of going from stable flight to unrecoversble spin stall in a matter of seconds. Even the POH of the aircraft itself states that if altitude or airspeed suddenly goes negative, to IMMEDIATELY ESCAPE that environment. LIKE A PILOT CAN DO THAT BY JUST TOGGLING A SWITCH. WELL IT TAKES PRECIOUS TIME TO DO THAT. IT IS A PIECE OF SHIT DESIGN IN iMC.
*I would say 20% pilot error and 80% aircraft design.*
1. *You already know an aircraft is rubbish, when a pilot has to declaire PanPan or MayDay, and priority, emergency landing for a little bit of wing icing.* Thats just crazy.
2. As a pilot it is not easy to handle something that in 8,000 hours of flying, ends in an uncontrolable flat spin within 8 seconds. It comes as a shock out of nowhere.
3. The ATR 72 500 is an old plane that is good, cheap and reliable... but only for good weather, and *we need to start asking ourselves, if this aircraft should REALLY be flying passengers or only packeted cargo freight.* 🙄
4. *God bless the passengers and God have mercy on the pilots. AMEN!* 🙏
Thanks!
Thanks! Appreciated!
Being assertive and proactive as a Captain is a must if you want to live long and prosper. I would not have hesitated to declare an emergency and tell ATC to get the conflicting traffic out of the way because I’m descending, like it or not.
Great video Stan. Nicely produced with a great analysis on operating procedures, CRM and human factors. One of the best ones I’ve seen so far on this tragic and sad event.
The questionable decisions started on the ground. Dispatch flight planning into known severe icing and the pilots accepting it. Everything else was icing on the cake. Pilots need to learn to say, “No”. Simple Risk Management.
Provided all the ice protection systems are operational, The airplane is certified to fly in icing conditions, they couldnt say no on the ground. They could however, have said no to atc when they were denied a descent clearence. Be more incisive, declare a mayday and descend anyway, or even do a 180, anything but what they did.
@@geraldo209 the airplane is certified to fly ->through
@@rafaelrafoso it certainly does. All im sayin is that the pilots couldnt say no on the ground, having all the ice protection operational, the airplane is certified to fly in icing. Obviously pilots are trained to leave and avoid icing condition whenever possible.
Poor company cant handle canceling flights. They pressure pilots to never cancel flights. Pilots fly, survive once and then keep doong it with the idea the rules are too severe.
@@geraldo209 no aircraft certified before 2015 is certified to fly in severe icing no, particularly not a smaller turboprop with limited ice protection
Congratulations for being brave and speaking the truth, just the truth. There was a decisive human factor, a decisive mistake everybody avoids talking about. You're the first not doing so. If one can´t face the facts, can't make aviation safer either.
This is the most solid overview I've seen yet. Still terrible to watch. I used to be a mechanic on ATR72s before I was an airline pilot. Jumpseat on them a few times throughout Alaska.
Brazilian 737 driver here. Very well content and video. It is very unfortunate, but truth what you have said and shown. And i have to thank you for having the guts to do it and show it. Thank you. You got a new sub.
Thanks and welcome
ATR 42/72 and DH -8 aircraft should never be certified for any icing.
As a Dash-8 rated pilot, I disagree. The Dash series of aircraft is very reliable in adverse weather, including icing. The Dash 8 is used by all 3 major Canadian regional airlines, and the Dash 7 is even used by many northern operators in Canada, where icing is a year-long concern. I've personally flown the Dash-8 through several Canadian winters, and it handles icing quite well. Can't say the same for the ATR as I haven't flown it.
They are certified because both types have satisfied the requirements.
Nearly 30 years maintenance experience on both types, trying to explain detection and protection in this system is more than a 5 minute conversation
I’m from Brazil. Great content! Rip to everyone involved
Excellent presentation and information. You also provide very important points on operational discipline when it comes to flying airplanes.
I was flying King Airs at the time of the Roselawn accident and several changes happened as a result. If I remember correctly, the FAA issued an AD related to flight in icing conditions for most Turboprop aircraft. If encountering severe icing, hand flying the airplane was part of the AD. It’s important to have the tactile feedback. I do remember that FSI added training scenarios in the Simulator. Regardless of aircraft type, if encountering severe icing take action to get out of it immediately.
You’re great at this. Another fantastic analysis!
Very good explanation. All those who comment on this accident avoid mentioning the rather obvious: the failure to continue the flight with an ATR in severe icing conditions.
I wouldn't make such an strong argument with only a preliminary report in hand
The pilots continued in icing conditions for an hour after the deice equipment failure. There will be some other details in the final report, but nothing that will excuse that poor decision on their part.
@@flyingformoney777 and the degraded performance alarm.
Maybe you wouldn't.....but it does make you look very foolish.
Good job! Let's see how the Brazilian mainstream media will portray the information on this video. I'm Brazilian, and we usually are very sentimental and condescending.
I hope my photo never shows up on a thumbnail under the title "HORRIBLE MISTAKE!" 🤥
It would be a ghost anyway.
Our ATR pilots diligently check the weather forecasts and delay or cancel the flight if known icing is predicted on their route. The APM system consists of accelerometers under the cabin floor, two TAT sensors, Ice Detector probe on the left wing. There is also an ice detector mounted on the fuselage left side window. This detector simply shows the Captain how much ice is accumulating. The engine inlets use inflatable boots as well. A faulty PACK does not have anything to do with the bleed air for the boots! This is a separate system.
He didn't say a faulty pack resulted in a boot fault. He said faulty pack, switched off for this flight, resulted in left engine delivering more thrust which resulted in right spin.
@@hndflights aircraft isn't faulty. None of the aircrafts flying is certified to fly in severe icing conditions and these are defined as conditions in which deice and anti ice systems may not be able to prevent/remove ice.
Every pilot knows that you either don't fly inro severe icing conditions or if you find yourself in such, you get yourself out of there asap.
These two seem to have been either unaware of danger they were in or disregarded procedures.
ATR are very good aircrafts. Nearly all crashes in ATR were caused by pilot error
@@hndflights what you're saying is exactly waht happens with EVERY aircraft. You have a whole book of emergency procedures and in emergency one pilot flies the plane and the other follows checklist.
Every aircraft has such procedures - boeing, airbus, dash, embraer. Just every.
If the design was poor and dangerous as you say, the aircraft would not be flying.
The PF was the captain who had considerable less experience on the ATR than the PM. The captain never mentions the word "ice" during the entire flight even though the outside visual ice detector probe is only installed on his side ...
On another note, there is a difference between flying into severe icing conditions and flying into KNOWN severe icing conditions.
Root cause of this accident was a complete negligent and incompetent flight deck crew!
The fact that American Eagle moved all their ATR's to Puerto rico says a lot about the aircraft's design
Thanks for speaking the truth. Some youtube channels from Brazil are simply avoiding to speak the truth
You have made a very impressive analysis and - even more noteworthy - you have articulated a powerful philosophy of aviation safety for pilots.
Condolences to the families and friends. Thank you 🙏 Sir for this educational video. May they rip Amen 🙏. Hi from Temple Terrace Florida. I’m a follower about airplanes accidents. 🇺🇸🇵🇷🇺🇸🇵🇷🙏🙏.
Good to listen to someone who knows what they're taking about.
What do they drum into us from Day 1?
AVIATE, navigate, communicate. Not just please ATC.
Hate to imagine the screams in that cabin from helpless innocent passengers who deserved better.
It seems to me that these pilots were used to flying in icing conditions and treated the checklist as merely advisory.
Despite how challenging it is to instantly escape the danger zone, I’ve got to say, you did an amazing job breaking it down in this video! Your explanation makes it much clearer.
first time viewer who is happy to have stumbled upon this video. Looking forward to watching many more of your productions.
Awesome, thank you!
Wow, this has to be the best video you have done yet! You really drove the message home. "Rules really are written in blood".
People always get sensitive when someone says that pilots make mistakes, acting like pilots are perfect, no, pilots make mistakes, guys, it is not unrespectful to tell the truth!
You're right. It is not unrespectful to tell the truth. The thing is, you don't know the truth. At this point, no one does yet.
@@MauricioGaldieriwhere do you keep your white stick?
As a former ATR pilot, this is pretty dead on. It's astounding it stayed aloft as long as it did, so I gotta give Aerospatiale credit where it's due. However, my experiences on the ATR-42, and ATR-72-212(A) were less than stellar. As such, of the aircraft ive flown professionally over the past 17 years, the ATR is the only one I will never step foot on again.
It’s a safe aircraft when flown by a competent, well-trained crew who is willing to pay attention and get out of severe icing (or refuse to fly into it). Being prepared to exercise emergency authority if warranted (done it 3 times in the ATR) and to know and follow the procedures is the key. Every aircraft has its quirks. I personally don’t like to fly Airbuses but I know they can be flown safely.
Thank you for your clarification
The aircraft ATR 72 is certificate for flight in know Icing Conditions, but the difference in this case is they flew in SEVERE ICING CONDITIONS. In this condition is not certificate any Commercial Aircraft.
Outstanding Analysis!!
I was talking with a lady 1 or 2 weeks ago, one of her friends works at Voepass as a pilot, one of his colleagues was involved in the crash.
Excellent, someone must to tell the truth, no to find someone guilty, but to avoid same problems in the future.
I think this is too forgiving to the company and it's too easy to blame pilots. Their biggest mistake was not saying 'no' to a contract that had them flying machines with critical systems INOP for over a year, if that is true.
Great video
Sensible and straight to the point
Something we will never know is how used to this kind of warnings they were. Sometimes people go through warning so often and nothing serious happen that they start to ignore it and think it normal. "oh it's fine, don't overreact just because this ice warning or low speed, happens all the time" It's like when you do some shit on the road and it works and u start to feel confident enough to do it always. I have no idea if this is the case, but I wonder if it can help to explain their lack of matter for all these signs
If we were to analyze all accidents as simply human causes, we would not get to the real causes. The actions of the pilots are all the result of the work of the companies, manufacturers and regulatory agencies. Therefore, all human errors are actually systemic fault. If the factors that led to these errors are not corrected, the risk of other accidents of this type will continue to exist.
Icing of the wings is one of most common cause of crashes. And yet they ignored it, and you want other reason.
Nobody talking about the malfunctioning ice prevention systems
Max power and pitch down for a spin recovery?? Is that aircraft type specific and if so, does that suggest this aircraft was spun in test flights?
Thanks for sharing.
I misspoke when I said “spin.” I was referring to stall recovery.
@@flyingformoney777 👍
@@flyingformoney777 th-cam.com/video/WOHTUmeGpnI/w-d-xo.html
I like your videos! Very descriptive and to the point!
..you have the voice of a lawyer 😅 great job!
Fantastic analysis and presentation !
You did an excelent analysis!
👏👏👏
when in icing conditions , if de-icing fails ... get out of the icing zone asap & increase speed ? one really needs to browse a manual for the obvious ?
Ok we are not the blame no one, is obligation to any pilots training ice conditions , they did not anything , despite many signs.
Excellent and clear video as always. Only thing, the reference to “around the equator” at 08:02 seems to imply that São Paulo is not too far from the equator, whereas in fact is very far from it. As a matter of fact, Mexico City (19°25’N) is closer to the equator than São Paulo, that lies at 23°32’S, only one degree LAT farther from the equator than Key West (FL), that is 24°33′N
Is Mountfield near the equator?
Did atr sponsor this video? 😢
I like this channel, just a question, where are you gleaning your information regarding what the pilots did or didn’t do ?
^ +1.
Let's hear the final report, shall we?
The CENIPA report, lol! You can read the damn thing and glean it yourself (in either english or portuguese)
An excellent analysis of the flight and the unfortunate crash. Although I haven't flown as a pilot in many years, I learned over 50 years ago that when in a questionable situation, "Aviate, Navigate, Communicate." I could not agree more with the need for the pilots to commence an immediate descent to lower altitude and to inform ATC that you are doing so. Not ask for permission. A Pan, Pan, Pan would have been appropriate.
Flat spins in aircraft with a high mounted horizontal stabilizer can be a chore to control the aerodynamic characteristics that a flat spin poses to that type of aircraft. Nose down, immediately increase airspeed to make certain the horizontal stabilizer has enough aerodynamic energy and airflow to give the aircraft pitch control in the vertical axis and the added ability to stop the spin.
Unfortunately, this accident happened, and my condolences to the passengers and flight crew.
We will never know if the doctors on that plane had the cure to cancer or why the other 7 took an earlier flight.
I dont see the mentioned link for that article you wrote...
It was at the end of the video. Here’s a direct link: www.twinandturbine.com/impenitent-ice/
Nothing worse than a timid, scared pilot, and flight crew.
human error is the main cause of almost all disasters
An excellent explanation of what went wrong, love your channel.
Thank you!
Why? Why would you turn off the airframe deice though? That seems counterintuitive to being in heavy icing conditions. And doing nothing as it pertains to the "hold at seventeen thousand feet" when you are loaded with ice seems insane?
They got the fault light on. The System wasnt working.
Agree with Geraldo + some of the boot sections could have been working and one (or others) not. Asymmetric de icing is worse than no de icing and could have contributed to the spin.
Thank you sir.
Sound judgement, they did not apply sound judgement. Icing is NO joke and I am absolutely terrified of it.
The Finns and Swedes use the atr 72 in the middle of winter and there has never been a problem with icing. Some companies should take two or three training courses in the countries mentioned above.
Very good video. Well and clearly explained. I learned a lot from your explanation . Good information. Congratulations.
*I would say 20% pilot error and 80% aircraft design.*
1. *You already know an aircraft is rubbish, when a pilot has to declaire PanPan or MayDay, and priority, emergency landing for a little bit of wing icing.* Thats just crazy.
2. As a pilot it is not easy to handle something that in 8,000 hours of flying, ends in an uncontrolable flat spin within 8 seconds. It comes as a shock out of nowhere.
3. The ATR 72 500 is an old plane that is good, cheap and reliable... but only for good weather, and *we need to start asking ourselves, if this aircraft should REALLY be flying passengers or only packeted cargo freight.* 🙄
4. *God bless the passengers and God have mercy on the pilots. AMEN!* 🙏
"2. As a pilot it is not easy to handle something that in 8,000 hours of flying, ends in an uncontrolable flat spin within 8 seconds. It comes as a shock out of nowhere. "
So... what about ignoring the problem multiple times? Is that an aircraft design problem?
@@livestock9722 you have never flown a plane in your entire life. We reset alarms EVERY SINGLE DAY. That doesnt mean the plane crashes.
@@herrguru4264 Assumptions kill pilots. I learned this very early on, in flight training. I'm surprised you're still around.
@@livestock9722Educate yourself
1. The ATR has had 67 accidents, resulting in hull losses and 530 dead people.
2. This year in 2o24 alone, there have been 8 accidents with the ATR 72 aircraft.
3. Most of these problems are with the deicing rig.
4. The job of a deicing machine is to deice and not to 6 false alarms when its working and 8 false alarms when its not working.
A linha entre as boas decisões e as más decisões são muito tênues. Some times...
Was it negligence, or poor training?
Negligence. Low speed alert, even me as a non pilot would know to increase speed.
@@focusaddiction3460I can see you have not a clue what you are talking about. You would have NOT known what to do in this case if you were in there as you have zero training.
Also poor training! This airline is very low quality about safety culture
@@AgonxOC Well, you say "you have no clue what you're talking about", and i think "i know what 'low speed' means". As long as you know english you should know what to do when the message low speed appears.
It's like if we had a monitor for our heart and the monitor said "heart attack!", i'd know i had to run to the doctor.
But if you think i don't know what i'm talking about, please tell me what you do when a plane tells you that you're in low speed, should go slower? I'm curious now
i'm 46 never saw one inch of ice in any plane in brazil, sounds ridiculous...
what method
Excellent synopsis, Stan.
As another commenter stated, thanks for not insultingly deflecting the responsibility of this incident off of those pilots.
Which is a faux pas amongst many self back patting pilots, who will continually blame the ATR-72. Regardless of reality.
Great content and detail, glad I found your channel--I've recommended it to several friends. Thanks.
Awesome, thank you!
50% pilot error, 50% risky/outdated plane design (don’t defend problematic designs - having to declare a mayday for severe icing regularly as a part of SOP sounds insane and is a disaster waiting to happen)
Nope. It’s ALL Pilot error. That plane was certified for FIKI.
They stayed in it and ignored the warnings INCLUDING their training on icing.
The plane did what it was designed to do. The pilots pushed it beyond its limitations.
There’s ZERO argument about that.
@@c208driver6yea most of it pilot error
@@c208driver6being certified to fly in icing conditions doesn't mean the airplane is ice proof. The result of an ATR flying into severe icing condition with some malfunctions spoke for itself, and it was not the first, second or third time. This type of airplane has a history of many similar incidents and crashes.
This crew believed they were doing the best they could, but unfortunately it was not enough
If I had a relative who was as a passenger in that crash , I would be deeply in pain. If I were the father / son of any of the involved pilots, I would be even more in pain, specially after such unnecessary remarks raised by this video
@@pedrohmu OK. So I have A LOT of experience flying in icing conditions. So I know what I am talking about.
The plane was certified and the pilots were or SHOULD have been trained to understand the limitations of flight into icing conditions in that SPECIFIC airplane. There is no airplane that is certified to fly into CONTINUOUS icing and that is EXACTLY what this crew did KNOWINGLY.
Even after they encountered icing and the equipment failed, they took NO ACTION to exit icing conditions which ALL pilots are required to do when there is either a failure of the equipment or the ice is overwhelming the system.
What they did was criminal. It was 100% their fault based on the facts of the case.
They entered icing conditions, had an equipment failure and then proceeded to continue to fly into it for an extended period of time in an airplane that has a history of not doing well in icing. There were even reports of severe icing, so it's not like they didn't know what they were getting into.
Icing is probably the most dangerous type of hazard in aviation. From experience, sometimes you have less than one minute to take action before it's too late. It's pilots that make the decision to stay in ice instead of exiting immediately that end up killing a bunch of people.
Furthermore, anti-ice/deice equipment is designed to give you time to exit the icing conditions when you encounter them, NOT to continuously fly in it. Especially when the equipment fails.
So 100% their fault. If they would simply have climbed or descended they could have gotten out of the situation. But they didn't and the result was a bunch of people getting killed.
it's clear you don't know what you're talking about
Inop A/C pack meant altitude was limited to 17.5. That put them squarely in icing conditions. This plane should never have been dispatched.
The Pack inop did not interfere with ice protection systems. Provided all the ice protection was operational, the airplane can be dispatched into icing conditions because it is certified to. The crew however should have left icing conditions the moment they got that fault light though.
@@geraldo209 Certs and MEL need to be looked at. IIRC, two packs mean plane can operate at FL24 which would have been above icing condition.
@@encinobalboaice can form on FL240 too depending on how bad the cold front youre flying in is. Fact is pack inop does not hinder the ice protection systems inop. Once they got that airframce deice fault light, thats a no go for sure, and they should have descended to fl100 or even lower. And it wouldnt matter to their fuel consumption anyway. Very sad.
@@geraldo209 I was referring to weather conditions that day.
the SIGMET said there was SEVERE ICE in that route and altitude, severe ice is an emergency as the ATR manual says, so is it right that the plane was dispached into severe ice? even with deice working?
Totally agree with you Sir. I just do not understand why the flew into that condition? Self confidence?
The ATR is not safe in icing period. It is an efficient turbo prop. Aerodynamically it is great and the HORIZONTAL tail is sized to be optimal. In ICE it is not sufficient. The ANTI ICE system and design is marginal. That tail should be bigger and NOT A T-TAIL. There has been many twin turbo prop airliner accidents realtered to ice, ATR being the leader in ice related accidents, To be fair, turbo props spend a lot of time in lower mid levels where ice is an issue. Jets in the mid 30's are not in ice conditions, and they climb and descend fast through lower level altitudes. I was offered a job to fly ATR as Captain for cargo. I almost took the job but kind of glad I passed.
I’m not sure what your issue is with T tail turbo prop aircraft, I’d assume you have an engineering degree along with you ATPL .
If you ignore and advisory of severe ice and make failed attempt to mitigate and avoid , you can never blame an aircraft.
I’ve spent nearly 30 years in aircraft maintenance and I’ve dealt with many whiny pilots that sound just like you .
@@duncandmcgrath6290 A poor workman always blames his tools.
I agree with Duncan. You missed a golden opportunity to increase your skills. I flew the ATR for 8.5 years before the RJ and look back fondly at that time. Yes I flew it in icing conditions and even encountered severe icing 3 times. It was a safe plane when you complied with the procedures or rerouted or delayed when the ice was going to be bad. Hopefully, you flew something besides an RJ before going to a major? Those folks and single seat fighter only pilots take the longest to become seasoned at the majors.
It wasn't a secret they would incur icing conditions on this flight. The problem is complacency as they were able to skirt by before.
The last 2 minutes of this "flight" must've been unimagimably horrific.
Outstanding analysis!!
Good talk. One pedantic note: Airliners haven't had steam gauges in 60 years. The round dials pre EFIS found in an airliner cockpit were absolutely electronic devices...analog electromechanical stuff with analog computing for various functions. Quite different than the true steam stuff in a vintage GA plane.
@@wgmskiing That really made me laugh. 60 years earlier from 2024, was 1964. While transistors were found in pocket radios. "Computers" were still IBM punch cards, feeding into a room full of Eniacs or Univacs. The 8O88 microprocessor was still more than a decade a away. Obviously you are someone that knows nothing of tech history at all. In the Boeing 707, state of the art in 1964, there does not exist any glass in the cockpit displays at all. The only glass is in the windshields, and the faces of the so called. "steam guages". I know, because I was actually alive back then. You obviously did notveven exist.
It’s an old school reference for analog that is laughable.
@@jakerabinz9411 I can't speak to the 707, but I can with some authority talk of the 727 because I have a project involving it on my desk right now. It first flew in 1963, and every one of the "steam gauges" was electronic. The air data computer was an analog electronic device. The auto flight system included discrete logic for gain programming and gating different modes. The altimeter, attitude indicator, HSI, airspeed indicator....all electronic devices and most included significant numbers of discrete transistors. A Cessna 172 of that era came with steam gauges, nothing but vacuum gyros and pito/static driven bourdon tubes.
How is it legal to fly with one pack defective? Wouldn't it be extremely dangerous if the second pack broke during flight resulting in no fresh air in the cabin?
There are ram air scoops to deliver fresh air if needed. The aircraft would slowly depressurize if the second pack failed but between descending and oxygen masks everyone would be okay.
@@flyingformoney777Thank you for your reply and answer. No air flow would lead to CO2 build up in the cabin. The brain chemoreceptors will start giving you that feeling of suffocation due to CO2 build up long before O2 drops enough to fall unconscious. Do you mean the ram air scoops work passively and independently of the packs?
@@themilkman7367 yes. They are often used to cool the pack heat exchangers (I.e. air conditioning the hot bleed air from the engines) but can be rerouted to supply fresh outside air into the aircraft.
@@flyingformoney777 Thank you for this information. It has always been a point of anxiety for myself, thinking that, should the packs go down, you're stuck in a sealed metal tube with who knows how many people exhaling co2. In physiology course, I was picked for the rebreather test. It consisted of a bag with 10 litres of pure oxygen connected to a device to measure breathing that you stuck in your mouth. I can only describe it as gradual horror as the co2 climbed giving the feeling asphyxiation despite there being more than enough oxygen. Horrific.
Why such a flowed air coffin still in air with 60 passengers ???
Good video. The plane turned into a brick which only Colonel Hawkins (Space Cowboys) could fly.
I think in most general aviation aircraft. The recovery for spin procedure is actually to reduce power to idle first. The thrust and prop stream actually interfere with the recovery for a few different reasons. Then you neutralize the ailerons. Then you use the rudder opposite to get out of the spin. Then pull out of the dive. Then add the power. This is a flat spin though things might be different. Its a bigger plane too.
I think when I started flying Cessna that was the protocol for a stall induced spin( power on stall) I’m not sure about a flat spin-I think most aircraft are not certified for flat spin
Multiengine airplane pilots would be very hard pressed to recover from a spin, because of the large moment of rotation from the engine mass, far away from the center of rotation. Very much more so in transport category airplanes, let alone in a flat spin where airflow around control surfaces is all over the place.
@@coriscotupi yes I’ve never flown any transport category aircraft and only flown light twins under instruction but I know that I don’t think there’s any transport aircraft rated for spinning for that reason
@@malcolmwhite6588 Exactly. I don't think there's any twin (even light twin) approved for intentional spinning, either.
@@coriscotupi no I think that would be a pretty sound statement that would not get contradicted by anyone in the know!
Hinton a name of person?
The deicing system repeatedly turning on and off was likely due to a malfunction, with the pilots making several attempts to keep it running (possibly because the system never fully activated). Repeating the process might eventually cause it to stay on.
The checklist says to turn it off for a reason. A partially functioning deice system can be very dangerous if only one wing is being deiced.
@@flyingformoney777 As I said.
Thanks for your explanation 🙏
There are many people who chose flying instead of farming.
🇧🇷here good video Well explained, here in Brazil the situation is not very good with the Twitter ban, I practically don't know any news, I'm just going through life blindly and find out about updates through your very well explained video
Very important information and analysis
This is what im afraid i guess alot of pilots are not well trained
The investigation into this accident is still ongoing and there are still many things to be determined. Only a preliminary report has been released detailing the situation. However, it is still too early to make statements as if the case has already been solved. It is also necessary to have a little respect, including for the families of the crew members.
Nice video.
2 points, though:
- using mostly the -600 cockpit sim for this video is somewhat misleading.
- there is no spin recovery procedure for transport aircraft like the ATR, especially not for a flat spin, which is likely not recoverable.
The plane in your animation is spinning in the wrong direction. The plane actually crashed spinning counterclockwise (to the left).
You wouldn’t believe how difficult it is to produce a flat spin in Microsoft flight sim. It went clockwise, I accepted it…
I was afraid this was the cause of the crash. Again the series of events that were left unattended getting you into trouble. Also twins once in a spin are very hard to get out of a spin if not near impossible--- sadly game over for them once spin initiated.
Thanks for a thorough and clear breakdown of this accident.
In a serious incident with an ATR-72-212 of TRIP Linhas Aéreas in a night flight in 2013, the aircraft enter in ice formation area - under autopilot control; the pilots activate anti-ice devices, but not the de-icing devices for wings and engine naceles, suffer speed reduction, stall and fall.
The pilots don't follow the aircraft manual procedures:
- The PIC fight against the stick pusher. Manual instruct lower the nose.
- The SIC ask if PIC want he turn of engines, have no response, so he feathered the propellers. Manual instruct set 100%.
Anyway the plane level at FL110 - after fall 5000 feet; and land safety in destination.
As the name says, this is a preliminary report. Also, you can see on the report that the request to descend was a "top of descent", not a request because of icing. But most important, even if the final report points several contributing factors about the pilots, you should remember that they also lost their lives. Their families and friends have to deal with the grief and also see the faces of their loved ones being used in thumbnails like the one in this video.
You can talk about the facts and be respectful at the same time. Look at the channel "Aviões e Músicas". It is from Brazil. The guy is respected in his field, has millions of subscribers, makes a lot of money, and you'll never see him pointing his finger in cases like this.
You're quite correct.... no one to blame, no errors, no negligence.... a perfect world.
Will wait for final report which hopefully will have a lot of input from USA.
I would not fly on this aircraft as it is too critical in ice
It's relevant to say that this airplane got only 1 pack operational, causing to trigger the airframe de ice fault... and of course to say... That the fault was not only by the crew, but also the ATC AND Airline itself. Airline put "some" Pressure on pilots for take off no matter what, (you can find footage of VoePass taking off in a middle of a major thunderstom, with windshear resulting in almost a disaster shortly after the take off), pressure to not declare emergency (in Brazil all panpan and maydays are investigated after the aircraft land, and punishment "applied"), pressure on pilots to not go around due to more fuel usage and aways take off with sometimes... enough fuel just for alternate, or even just for one go around, no extra fuel for holds etc etc. This aircraft had a tailstrike months before the day of accident, airframe repairs was done, and was forced to take off without landing gear operational (Extended), this aircraft in the day of tail strike flight; failed completely the right wing anti ice boots, and the left half operational... And also the company lack of "trainement" (again increasing the workload on the pilots), in ice conditions. This airplane was an ice brick, they did it before... hot summer, descending the ice ll just melt and good to go. (In their minds... They did several times... Whats wrong to do it again?) With this lack of awareness, and pressure by the company... MAYBE, the pilots didnt understood the BIG problem they were facing and, not even the emergency checklist was possibly conducted. The ATC cleared them for a right turn for an initial fix, prior to execute the SBGR STAR, but to STAY at FL170... they replied, and with a big "THANKS" in the final reply, did the turn... and almost imediately the flying ice brick... stalled. On my company several pilots fly this kind of equipment... in the same situation +50 knots of present speed, in the moment of the first ice alert... ALL DE ICE and ANTI ICE ON... and IF the Alert insists... mayday mayday mayday, nose down, prop 100%, engine 100%, a bit of overspeed flying STRAIGHT until the ice melt. Sadly, its not only a pilot factor here... but begins, with the company... going thru the pilots, AND THE ATC. Im speechless with preliminar reports... with 737-700, facing severe ice between 160 and 250... when entering below 250... we just REFUSE to turn, following the STAR path, 99% of the times the ATC got pissed of... we just answer back "SCREW YOU, LACK OF PERFORMANCE, WE LL MAINTAIN HEADING" and he clear the path ahead. This simple. But... Why Im speechless... They not only followed the ATC instructions... and said "THANKS" but also REDUCED the IAS to 169 knots... Oh God have mercy and RIP to all souls on board.
A litle hard in the words about the pilots....but...is like you saying..." Its not time to be cute". Good video...true and educative...
Question: What about the co-pilot? No action? Why do we have 2 (two) pilots?
He and the PIC are focused in COMMUNICATE, leaving the AVIATE, NAVIGATE with the autopilot.
@@Sokol10 .... they almost didn't comunicate!!!
Say they made a mistake or they were negligent with correct procedure is what midia is doing. Human factor is part of every accident, the difference is knowing WHY they didn’t what they should have done. Everyone that flies in airliner is thinking why there were so many warning and none reaction, but the essential will be discover WHY, not just know they didn’t.
Airline culture, training, SOP, CRM, AFM, FOM, line culture, line checks, hiring practices, cockpit discipline, upgrade requirements, pilot history need a good look. The known facts point to human factors.
the penguin shirt! haven't seen this in years
Being certified to fly in icing conditions doesn't mean the airplane is ice proof. The result of an ATR flying into severe icing condition with some malfunctions spoke for itself, and it was not the first, second or third time. This type of airplane has a history of many similar incidents and crashes.
This crew believed they were doing the best they could, but unfortunately it was not enough
If I had a relative who was as a passenger in that crash, I would be deeply in pain. If I were the father / son of any of the involved pilots, I would be even more in pain, specially after watching a video and comments full of overly unnecessary remarks.
But you are none of those people, and yet you are offended. As far as being a pilot goes, I am hard on myself too. I truly feel for the sufferings of the loved ones, but I’m more concerned with emphasizing to other pilots the errors that were committed here in order to save future families from going through what these families are going through.
@@flyingformoney777 It's true. I'm not one of them, but it doesn't mean I can't put my self on their shoes.
As a pilot, I believe that the concepts of leadership don't give me the right to act hard because it would brake the communication chain with the crew, and I am the final one who most need to receive the best communication and the best preformace from the crew. This is only achievable on a good created environment.
Statistically, any crew member, including me and you, make at least 5 minor mistakes during any flight. So in my opinion, being too hard or either too soft is undesirable, specially when dealing with thousands of lives each month.