VoePass ATR CRASH - CENIPA Prelim Report

(Please Subscribe!) The Brazilian agency CINEPA has put out the prelim report on the VoePass ATR-72 that killed 62 people on August 9, 2024 outside Sao Paulo. Dan walks through the report.
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[@OMG_No_Way]

Can’t believe there’s so much detail in a prelim report. Maybe the NTSB can learn something.

[@JustaPilot1]

One can hope

[@JoshuaTootell]

I would be curious how many GA accidents Brazil has to manage investigating vs the United States.

[@57Jimmy]

That would mean they would have to actually work and not give the pre-programmed response wheel a spin to blurt out a generic description!🤭

[@andrebello4191]

Sometimes its easier to figure things out sooner based on what information is available and depending on circumstances I guess. Each accident is just different I guess. Just the fact that this happened over land and not sea makes it easier.

[@geraldo209]

@@JoshuaTootellnearly not as many as in the US. As aviation in Brazil is maybe half the size of US aviation industry.

[@XavierLignieres]

It’s both sad and frustrating to hear they ignored all the warnings and did not take decisive action. My instructor once told me “If you ever get in an emergency situation flying the aircraft to safety should be your top priority and ATC can wait until you have taken action to get yourself your passengers and the aircraft to safety it’s better to have to explain your actions to authorities later than the possible alternatives if you delay taking action to get permission in an emergency situation”

[@bodystomp5302]

It befuddles me how two pilots would knowingly fly into severe icing, driving an aircraft notorious for fatal icing-induced crashes.

[@XavierLignieres]

@@bodystomp5302 We do not know if they actually saw the SIGMET yet. The very definition of severe icing is that its so bad the aircraft ice protection can not keep up with the speed at which ice is building up.

[@rc70ys]

The pilot was too busy making tik tok videos he seemed to enjoy being in front of a camera. I’ve said it all along pilot error. These planes are no joke and require your full attention

[@rc70ys]

@@bodystomp5302 One pilot was too busy making social media content based on his previous uploads of him being everywhere but the cockpit ! Sad reality. I’m sorry may all RIP.

[@cail171]

Why are there not cameras in cockpits yet? Cabins as well? Especially with how many fights happen, ppl end up kicked off, opening doors etc etc. other modes of transportation are allowed security cameras and jobs why not airplanes

[@donalddepew9605]

Very sad! Looks like the plane was doing its best to warn these pilots that they were getting into trouble. Been in icing conditions almost everyday flying over the Rocky Mountains back and forth. One thing I must let other pilots know, that anti and deice equipment just gives you more time to exit icing conditions in a safe manner. One carrier I flew for was adimant that you exit icing conditions any way you can. Great Video!!

[@VedaSay]

Its important for pilots in every geography to realized you are the only authority in that plane. Make decisions for safety of all. Not the dispatch, not the control tower...you are the authority.

[@jonesjones7057]

As an airline pilot and many times, a passenger, I can not even fathom the fear and misery for those passengers. I truly hope there is a special place in heaven for anyone that has to suffer through such a long feeling of helplessness and fear. It is just beyond comprehension. Prayers for all of them and their loved ones.

[@TrainerAQ]

Yea. I can't even imagine it. It's like Air France 447 or the German Wings crash where the passengers and crew are just strapped to their seat for long and horrible 4-5 minutes falling out of the sky before actually perishing. The panic and desperation must be unreal

[@Wes-o7y]

There are no special places in heaven for anyone, there are many people who have suffered horrific deaths, they are not the only ones.

[@adamknight4087]

As a retired Cpt 737 De-iceing is imperative! Also in any emergency FLY the a/c & nav. Sod ATC. Watching the news it was obvis the a/c was in a full deep stall!

[@DouradaBambina]

There’s love beyond our human comprehension in. Heaven

[@DouradaBambina]

@@Wes-o7yPlease watch some NDE’s or volunteer in hospice. It may erase your cynicism

[@musschootski]

Scary, and appreciative that CENIPAS released so much factual information.

[@jerry2357]

3:22 Supercooled water is actually missing nuclei (not kinetic energy) to allow crystallisation to occur. Any small solid particle (known as a nucleus) in the liquid drop would allow it to freeze. This could be a speck of ice or a speck of dust. It's more difficult to create an ice nucleus than for an existing ice crystal to grow, or a new ice crystal to start growing on a solid surface. Disclaimer: I'm not a meteorologist, but I am a chemical engineer who has a reasonable understanding of crystallisation from my professional work.

[@GlutenEruption]

Exactly. Kinetic energy has nothing to do with phase change mechanics or crystallization in this application. Also it's probably important to note that a piece of dust or a particle isn't required for nucleation (although dust and dirt on the leading edges certainly contribute) - nanometer scale surface features of the leading edge provide excellent nucleation sites (and even more so if the material is colder than the drop) and once formed, ice crystals offer even better nucleation sites leading to rapid crystal growth.

[@jerry2357]

@@GlutenEruption Yes, but I didn't want to get into the complications of nucleation and metastable zone width etc.

[@Riverplacedad1]

I remember being a passenger on a Horizon ATR from SEA to Wenatchee. I had just flown an A320 into SEA and have to admit got quite a bit of ice on the descent. Well the Horizon pilots got into icing. Props were slinging it into the fuselage which really gets ones attention. Guys made an immediate 180 back to SEA. Damn good head work on their part

[@redbird444]

Horizon never operated the ATR. They fly the Dash-8 Q400.

[@duncandmcgrath6290]

Nice try , they’ve operated everything but ATR

[@duncandmcgrath6290]

@@redbird444Not anymore , Embraer 175’s now

[@redbird444]

@@duncandmcgrath6290 Correct. I should have stated “they flew”. My error.

[@Riverplacedad1]

Ahh sorry about that Dash8. Believe me that ice sure got my attention. Had a 2 day layover in SEA and was really hoping to spend Christmas with my in laws but happy those guys made the right choice. Had a bunch of ex Horizon guys as my copilots. Real sharp

[@Bugdriver49]

I was flying an ATR-72 in 94 when American Eagle 4184 went in near Roselawn, Ind. I remember well the extensive testing that was conducted after that accident in order to gain a better understanding of the icing vulnerabilities of the ATR-72. Hours and hours were spent flying a-72 behind an Air Force tanker modified to spray water in many different forms, from a very small droplet mist to much larger.....and at different altitudes and temps. Discovered some deficiencies in the coverage of some de-ice boots which they then modified by extending the outboard section of the wing de-ice boot further back along the wing.... and gave special training to us, the captains on methods of determining the type of ice that may be forming on your aircraft. Don't get me wrong, I think the ATR-is a safe workhorse of an aircraft, but any safe airplane can and will hurt you when it's systems are not correctly utilized. My heat goes out to everyone lost in this tragedy. Salute :^)

[@TakingOff]

In my research, I talked to someone who did some of that colored water testing. Pretty amazing what you guys did.

[@redbird444]

So was I. IMO, the ATR remains a more sensitive aircraft in icing conditions, despite the “fix” to the outboard boots as a result of AE 4184 and testing. Crews need to be much more assertive in exiting icing conditions in anything more than traditional light icing.

[@jochenheiden]

I figured this was icing related. I didn’t know the pilots would be so negligent though.

[@johndonovan7018]

its like intentional. murder suicide.

[@sierramikekilo6925]

​@@johndonovan7018there's always someone jumping to conclusions too early

[@johndonovan7018]

@@sierramikekilo6925 is it. i said the day it happened its pilot error and planes do not just drop out of the sky. so many like you were "muh conclusions". shut up. this is literally murder to fly into ice with system fault, ignore all warnings, ignore the plane literally slowing and stalling and flat out refuse to do anything about it. this was murder pure and simple. way beyond negligence. this was willful akin to the german wings pilot flying into the mountain. the ATC speed log showed speed issues long before they got anywhere near the end. which would probably account for the times they were fiddling with the ice boots turning them off and on. i called out the atc radar speed log too on day one... "muh conclusions". no. they were icing for good 35 minutes before they crashed with very noticeable effects. they knew, they chose to continue. murder, by definition.

[@JohnS-il1dr]

​@@johndonovan7018more like the pilots underestimated the icing possibility because they were so close to home.

[@johndonovan7018]

@@JohnS-il1dr Not a wrong theory, and also others have said that since it doesn't snow in brazil, ice has a different meaning in ones head. you dont exactly climb to 20000 ft to experience ice on your local stroll to the mall. however, there were so many definitive warning signs that something wasnt right you dont need ice itself to tell you something is going wrong. even if we remove ice as a substance, they still did nothing.

[@Chainsaw-ASMR]

Many thanks for mentioning, at the very beginning of your video, the families and loved ones of those who perished in this tragedy. I watch a lot of KZbin videos about air safety (because I’m a nervous passenger) and I wish more channels showed this level of compassion. Y’all do a good job all around!

[@heydonray]

DO NOT CONFUSE the a/c packs with “the pneumatic system”. An inop pack does NOT mean that de-ice was compromised.

[@flymachine]

I have seen footage of crashes and even saw a light sport crash myself but I don’t know why this one has traumatised me so - the thought of the pax and crew being slammed up into the ceiling on impact is too much to handle, not to mention the unthinkable horror of experiencing a vertical flat spin in an airliner full of souls and the haunting sounds of an extreme, unrecoverable upset in a turboprop and watching the last moments of these people’s lives was deeply upsetting for me. I also have a special affinity for the ATR so to see it just stop flying is something I will never get out of my mind. RIP - Superb work on the prelim by the Brazilians.

[@berenonehand]

1 comment and 3 questions. Comment: 3:33 It's not kinetic energy from the collision of the droplets to the wing that causes the formation of the ice, it's the surface. The wing surface acts like a seed crystal. Q1) It would be great to have an explanation for why a pilot might repeatedly turn the deicing system off then back on again. Do the boots continually cycle between inflated & deflated while it's on or something, and so the system is turned off after a couple of cycles because it's presumed to have done its job? Q2) It would be good to get an explanation for the Fault alert - does "Fault" in this context mean the system's not working? Or maybe that the electronic circuit that feeds power to it isn't working? Q3) It would also be good to hear what impact it has on the deicing system to only have 1 of the 2 pneumatics working that feed the compressed air. Does that mean it only inflates the boot halfway? Or that it takes twice as long perhaps?

[@alfredomarquez9777]

EXCELLENT QUESTIONS THAT ARE FULLY UN-ANSWERED YET... As an engineer/pilot, I would add that the particular design of the Turboprops like the two ATR models, as well as the Strtched version of the ATR-72, results in a multitude of Design Compromises: in a few words: a) Limited effectiveness of old style Pneumatic Boots Deicer... as the ice STILL can (and will continue to accumulate) to the rear of the Boot edge... b) The selection of a "T-tail" style of empennage, that favours a Deep Stall or "Superstall", especially when the narrow chord high performance wing aerodynamis profile, has a quite abrupt and unfavourable Stall... c) having a "Stretched" version tgat results in a too long fuselage, that was balanced for proper C.G. by placing the Cargo/Baggage compartment to the front of the wing, between the passengers section and the cockpit... that will balance "fine", but now the Mass Distribution will result in a higher "Polar Moment of Inertia", because the mass is placed farther from the C.G., and that is aggravated by the placement of the two heavy engines, placed farther to the sides of the centerline, to accomodate the propellers clearance to the fuselage sides... ONCE a strong yaw statsctonspin the plane, it will make impossible forvthe relatively small area of the rudder to stop the flat-spin... And it seems that it will be much easier to put ALL.tge blame on the pilots, than going to the truoble of REDESIGNING the entire plane...

[@berenonehand]

@@alfredomarquez9777 I hear ya on the flat spin....but if you can get the nose down and you have a bit of time/altitude, theoretically it's possible to dive & correct the spin isn't it? I understand there must be a very strong inclination for a pilot to max out thrust in that situation instead of cutting it to get the nose down...

[@redbird444]

My bet is they turned the system off after the fault and simply forgot to turn them back on. With only one AC pack operable and maximum altitude for single pack operation, the system may not have had enough pressure capability to operate the boots in certain conditions, thus the initial fault. The ATR deice boots operate with 2 sets of VERTICAL bladders on each wing in opposition going back and forth. Once reselected, if they functioned at that point they MAY have begun to break-up the ice on the boot, but that MAY have then produced a ridge behind the boot (even the extended wing boots), thus resulting in a classic hinge-moment reversal much like AE 4184. The “vibration” heard sounds much like AE 4184’s “buzzing sound” just prior to control loss which was likely the ailerons reacting to the turbulent airflow from the contaminated airfoil surface forward of them as a result of an ice ridge. Also, we must remember that the horizontal tail was also iced up as well, and the smaller tail surface tends to ice more rapidly. IMO, there IS similarity of this accident and AE 4184 in the BEHAVIOR of the aircraft with ice accretion, even though it arrived at the control loss through negligence of the crew. The aircraft violently rolled one way and then even more violently the other way, which is EXACTLY what AE 4184 did.

[@reekinronald6776]

@@redbird444 I'm curious what the regulation is for a fault light on the de-icing? I would think that there would be some regulation/rule where if you are not confident on whether the de-icing of your aircraft is operational, you must abort the flight or fly at an altitude under non-icing conditions.

[@redbird444]

@@reekinronald6776 One would assume the checklist item for that situation involves avoiding icing conditions, or if in them to immediately exit them. Why they did what they did, I don’t think we’ll ever know for sure.

[@reyesben]

One of the best quotes in aviation superior judgment, trumps superior skills

[@guidospaini7339]

Thank you. Very pertinent analysis and comments.

[@ghtaboma]

Those poor passengers. Upside down, straight down, left, right, stuff crashing down on them. What a terrible way to go.

[@TrainerAQ]

And to do that for 4 whole minutes

[@philiphumphrey1548]

Sounds like a case of "Get-there-itis" on the part of the crew. Probably other factors involved, fatigue, pressure of work etc. which the full report will have to address.

[@ddthompson42]

I SAID EXACTLY THIS. Did the crew allow the plane autopilot let it trim the plane to keep the altitude, which made it impossible to recover. It was super obvious, but I didn’t know if the ATR systems would allow that to happen. Absolutely insane to let this happen.

[@johndonovan7018]

yeah some of us called it. all recent atr crashes have been human fault. i dont know how the SIC had 3k hours in the atr and nothing set him off he was bleeding speed... absolute madness. this goes beyond negligence, borders on murder. they knew.

[@KevinSmithAviation]

Thank you for the update Dan. So very sad to know that it could have been avoided. Keep up the excellent work. Safe skies my friend 🇺🇸🛩️

[@RobertBitzer]

Excellent, respectful explanation of the prelim report...keep up the good work!

[@shellyj7536]

I love your channel, told in a way that the bumpkin like myself can understand 😂 Just discovered your channel recently & thank you ...South African fan 🇿🇦

[@TakingOff]

Welcome aboard!

[@shellyj7536]

@@TakingOff Thank you ✈️

[@btoexport2]

I live here in São Paulo. We are about 50 miles from the place of the crash. Since the start, I found very strange that the two pilots did not alert about the ice or asked to descend. Very strange. Will we ever know what happened inside the cockpit ?

[@TakingOff]

I think they’ll be able to answer some of these questions.

[@btoexport2]

@@TakingOff Lets hope so

[@NicolaW72]

The CVR was completely readed out and the FDR provided important information, too, so it´s pretty clear what was going on inside the cockpit, what the pilots did - and more important in this case: what they didn´t. They flew round about an hour through severe icing conditions, most parts with the de-icing-system switched off. It´s amazing that the Aircraft remained so long in the sky. A couple of alarms were simply ignored. When the three last alarms blared, every one of them calling for immediate action, they were distracted with radio communication to the dispatcher, radio communication to the ATC, Pilot Announcement, Talking with the Cabin Crew, starting the Approach Briefing. The SIC finally recognized "a lot of ice" but no immediate action was taken to exit this area. Finally they turned even into the curve, increasing their stall speed drastically. It was no wonder that the Aircraft finally crashed. The question is why they acted in this way. The Preliminary Report points out that both Pilots were succesful in dealing with such conditions in their training. So why didn´t they implement their knowledge when it was crucial to do so? Hopefully the Final Report will answer this remaining question.

[@noneofyourbusiness5074]

That shows the ATR is not sensitive to ice in my opinion, the plane flew for a whole hour under severe ice conditions with pilots apparently not giving a damn about it, really impressive from the aircraft!!!

[@TrainerAQ]

Yea. Plane was very resilient towards giving the pilots more than enough time to escape

[@alfredomarquez9777]

Uninformed comments both: The ATR-72 (as well as the DH DASH-8) are both "Stretched Versions" with a too long fuselage. That creates a not-favorable high Polar Moment of Inertia, because the lenghtened passenger section is balanced by placing the Baggage/Cargo hold in front of the wing, between the passengers and the cockpit. Plus the heavy engines are far from centerline (to allow the propellers to have enough clearance to the fuselage... that fact results in a greatly increased "POLAR MOMENT OF INERTIA"... thus, when the narrow chord high performance wing (that has a too abrupt stall characteristic) does stall, the fact that the tail is a "T-tail" style, favors going into a "Deep stall" also called "Superstall", as the high placed stab and elevator get fully blanketed by the wing at the high angle of attack, which aggravates the stall, and when the stall happens, it is very easy to develop an spin, which goes into a Flat-Spin (Clearly visible in the videos), that is IMPOSSIBLE to stop and recover from. Apart from any crew lack of attention, there are now SEVERAL crashes of the ATR (Both models) as to deserve a much better redesign than the mostly "cosmetic" enlargement of the Deicing Boots, as ice CAN STILL CONTINUE TO ACCUMULATE behind the rear edge of the enlarged boots, especially on the very narrow boots at the horizontal stabilizer. Unless the entire tail is enlarged (which ATR makers will NEVER TOUCH), the vertical stab and rudder will be fully stalled during a flat spin. And training ATR pilots to make assymetric throttle inputs as an attempt to stop the flat spin yaw, is likely never going to happen, as it would be like an acceptance that the design is too vulnerable in icing conditions... it will be WAY MUCH EASIER to put ALL the blame on the two pilots that cannot defend themselves, than to risk damaging the "prestige" and sales of the ATR product...

[@rilmar2137]

​@alfredomarquez9777 the moment of inertia was something I have been thinking about in context of this crash. The question is, would asymmetrical even be enough to combat the spin?

[@OOpSjm]

​@@rilmar2137 A spin is not recoverable in commercial aircraft. It just isn't going to happen.

[@redbird444]

You would be incorrect. The airfoil of the ATR IS more sensitive to ANY contamination vs. most other aircraft. Even though the crew appears negligent in operation LEADING to the loss of control, once control is lost under these circumstances, recovery is unlikely. The aircraft didn’t “stall” in the classic sense, it became laterally unstable with a series of violent roll reversals, which is the hallmark of ATR high AOA loss of control. AE 4184 did the exact same thing, they just never got to a flat spin, but instead a vertical (partially inverted) dive and ultimate airframe overload in an attempted recovery.

[@alanluster950]

180 degree turn saved my ass a few times.

[@echo-trip-1]

That last photo of the crashed plane as seen from above at the end of the video shows how it came within a couple of feet of the house next to it. Unbelievable.

[@redbird444]

The ATR’s history of icing-related loss of control involves exactly what occurred here, that being a series a violent rolls that reverse. It occurred here, with AE 4184 and several previous loss of control incidents at the same carrier and in Italy in 1987. If they occur in IMC, it’s unlikely recovery will occur. BTW, the rudder is mostly locked out at higher speeds, so pilot input is limited. This particular airfoil is known for lateral instability in the stall regime, so while the reason for the loss of control may be as a result of crew negligence, the behavior of the aircraft is exactly what has occurred in the past.

[@ragnardanashold]

.... I've been waiting on this report from you.... thank you for the update Best regards always

[@NicolaW72]

Thank you very much for picking the Preliminary Report up and discussing him in such an informative end enlightening way!👍 - I must confess that I´m disappointed that he wasn´t mentioned on any other of the usual Channels about Aviation. He teaches indeed a lot and contains much more information as usually a Preliminary Report.

[@Coops777]

Thankyou for a very informative video. The report from Brazil was very comprehensive and a credit to the authorities who investigated and produced it. Dan, you mentioned a yaw was needed to commence the spin. From what you stated, the aircraft began loss of control at the commencement of the turn requested by ATC. I'm curious to know if the turn was performed at a high angle of attack. While I agree we shouldn't be quick to judge the pilots, I'm left wondering why they didn't ask ATC for more information about the conditions when they repeatedly had ice warnings and then aircraft performance warnings. They also should have been aware of the fact that the auto pilot should not be used in such conditions as it masks gradual performance changes until it exceeds limits, suddenly shutting off and leaving the aircraft in a possible dangerous attitude. I cannot help but think it was engaged for the majority of the flight due to both pilots' casual attitude to repeated warnings. There appear to be so many holes in this swiss cheese, there is barely any cheese at all.

[@TakingOff]

It could be the turn, but my research with ATR pilots think it more likely a subconscious push on the rudder pedal- they see this in the sims a lot where the pilot swears he never touched the rudder. But I didn’t include that because it’s speculation.

[@leokimvideo]

Crews so relaxed because Autopilot is doing all the hard work. They never read the checklist that in icing conditions Autopilot is to be turned off

[@Vontai21]

What an incompetent crew. That is actually insane.

[@agauerm]

You would think that a pilot with 700h flight experience in that craft, and the other with over 2.000h would be pros in it already.

[@lucasmatsuoca]

@@agauerm that's probably worse, I guess they had so many hours that they lacked that awareness. A New pilot would be more cautious with all the alarms. If you think about it, they were literally about to descend to land (Denied by the air traffic controller because there was another plane close). Which means that had this other plane not been there, they would have descended to land, regained velocity, they would get rid off the ice, and they would never imagined they were absurdly close to a crash. Which also means that they already flew many other times like this and very close to crash, always pushing the limits a little bit further and further. This crash was literally a matter of time unfortunately.

[@k9killer221]

Extraordinary complacency.

[@AlanToon-fy4hg]

The aircraft was smarter than the pilots.

[@LucasSanRFS]

It's not a final report, you can't blame them yet

[@alfredomarquez9777]

I Strongly disagree with your disinformed comment: As an Engineer, I can tell you that the Design of the ATR (and the DH Dash-8 400), especially the "Stretched" versions like the ATR-72, with their too long fuselages, narrow "high performance wing", a T-tail, and a cargo/baggage compartment between the cockpit and the wing, all those peculiar factors contribute to create a quite VULNERABLE airplane to enter a spin, and too easy to get into a "Flat-spin tvat is IRRECOVERABLE. Quite apart from crew mistakes or complacency, this airplane design is more vulnerable to icing and especially to enter a flat spin that was clearly recorded in the videos.

[@BkNy02]

That is not a misinformed comment. Multiple warning went off in the cockpit that was ignored by both pilots. That is negligence plain and simple. A basic pilots task is to prevent stalls. Especially on planes more resistance to stall recovery.

[@DouradaBambina]

Insensitive and unnecessary comment

[@reekinronald6776]

@@DouradaBambina Was it "unnecessary"? Although the final report is not out. It certainly looks like negligence, even criminal negligence. If so, it is correct to insult the pilots. We have lost the idea of shame in our society. Shame makes us perform and act better. We need more shame. Pile it on.

[@paulazemeckis7835]

Those poor pilots & passengers enduring all those g-forces and being pinned to their seats while rotating. Beyond sheer horror.

[@2TakeMe]

I think you answered yourself. Remember the last radio com was to direct to a point. Coupd it not be that a turn increased the load on the inside wing (not sure if it was left or right turn) causing it to stall during the turn which would cause incipient spin which developed into the full spin. Either way their wings would have been packed with ice completely changing the airfoil.

[@deusaero5195]

Great analysis sir 👏🏼

[@MegaSunspark]

The first thing that prospective pilots should be taught and tested on is their critical decision-making skills and capability. The pilots should be regularly tested on it throughout their career. This is so bizarre how these pilots repeatedly ignored all the warnings the aircraft was giving them. They should've read the meteorological reports carefully and avoided that airspace completely. Ask ATC for reroute due to severe weather conditions on the flight path.

[@johndonovan7018]

it doesnt compute does it...

[@PatrickJWenzel]

That’s an interesting point. If not tested perhaps taught to a level of competency during commercial licence training in oder to prepare them for airline standards.

[@johndonovan7018]

no testing can test you for "are you blind and not seeing and feeling what the plane you are in control of is doing for an hour before it crashes".

[@davidsine4390]

I cannot speak directly about the ATR, but in general, these aircraft have two seperate bleed air sources, one from each engine, not counting the APU, and two seperate AC packs. If one of the packs is inop, that likely would not affect the two bleed air sources. Therefore the de ice system would not be degraded due to lack of sufficient bleed air (if it's even degraded with only one bleed air source at all). Assuming both bleed air sources were available. I doubt the lack of bleed air was an issue. If only one bleed air source was available, and the de ice system performance is degraded in such a configuration, then it would certainly be required that icing conditions be avoided.

[@BrianJohnson-cj8xf]

I mentioned in a previous post on this crash that I was in an MU2 and we went through a cell and picked up a load of ice and it was in the intakes and on the bottom of the wings and I am sure the airframe and we could not climb above 12,700 ft and the indicated airspeed was back to about 115 kts.. We had to ask for lower, went down to 7000 feet, burned the ice off and then climbed up to FL240. Point is it happened so fast, I have no idea why that crew stayed where they were. They seemed too be to high, to close to the airport for me, but I was not there and not flying. BUT your video was very well done explaining what went on. Thank You for your video. Awesome Job. Thoughts are with the families who lost loved ones in this very sad and avoidable situation. Why would they stay in that ice ... when I see an ice indicator outside the Captains Window is even more confusing !!!!!

[@gerardmoran9560]

Great analysis!

[@skyking0475]

I flew the ATR for AE in 1999. We avoided icing at every opportunity.

[@fahadali5046]

Outstanding video 👍

[@franksgattolin8904]

Very well done presentation. Did this ATR-72 have the deicing boot update/mod? Many were sent south after Roselawn. Keep up the good work. Thanx

[@sibtainbukhari5447]

How does a crew of more than 10000 hours between them behave like this is beyond me .

[@stab74]

Normalcy bias? 🤷‍♂

[@bodystomp5302]

It’s beyond my comprehension.

[@TrainerAQ]

You get desensitized to danger

[@MatthijsvanDuin]

Raises some serious questions about training

[@MatthijsvanDuin]

@@TrainerAQ You don't normally get desensitized to fault warnings unless they happen semi-regularly and there's a habit to ignore them in the airline

[@peoplesambassadordm8279]

Great line. Superior judgements trumps superior skill.

[@daveroche6522]

Possibly another example of "'Get-there-itis"? Also, when we're really - really - focussed on a specific task (even studying - especially studying) our sense of hearing tends to 'drop out' - essentially all sounds being 'tuned out' by our brain. Just ruminatin'. R.I.P. all.

[@InMyBrz]

As an American living in Brasil, this is very sad news BUT I am not surprised. Those guys knew what they should do but didn't do the right thing Brasilians are not used to upsetting the apple cart, more or less passive Passive doesn't work when you need to be active in a particular situation, it kills you and everyone else

[@acaptain5118]

Exactly correct with this assessment. In flight instruction and aviation, this is one of the 5 hazardous attitudes called Resignation - Resignation is the feeling of powerlessness or the belief that one’s actions do not affect outcomes. Pilots and aviation personnel with a resignation attitude might abdicate responsibility, avoiding assertive actions when required, which could lead to unsafe conditions. For instance, a resigned pilot may not take corrective action during an equipment malfunction, relying on fate instead of proactively addressing the issue. Bad, bad, bad cultural issue when it comes to Brazilian Airline Pilots.

[@agauerm]

@@acaptain5118 where is the research showing that brazilian pilots have more resignation than other nationality pilots?

[@bodystomp5302]

Very well presented video.

[@TakingOff]

Thank you kindly!

[@solcarzemog5232]

Amazing video, very professional, clear, to the point, easy to understand. Bravo!

[@major__kong]

NTSB Preliminary Report template: An aircraft crashed.

[@stab74]

Woah woah woah there crashed is a pretty harsh term we haven't investigated yet! How about, departed from controlled flight, umkay?

[@TrainerAQ]

Pretty much

[@manuelportilla6092]

If an aircraft stalls and it bancks a little. If you apply oposite aileron. You go from a spin into a flat spin. You should never touch your ailerons. Only rudder.

[@andyasdf2078]

Thanks, Charles Lindbergh

[@carloscortes5570]

​@@andyasdf2078😂😂😂 great 👍 assessment!!!😂

[@carloscortes5570]

U need to listen amigo!! The expert man here says no yaw!! No rudder!! No pedales amigo!! That's what causes the unrecoverable spin..no digas disparates!😂

[@manuelportilla6092]

@@andyasdf2078 Naaah. Just your humble aerobatics pilot that considers that spin recovery should be mandatory. Not only on paper. PS. Include horrizontal high speed spins.

[@bennyF52]

@@manuelportilla6092I appreciate your comment. Maybe there is a newer pilot who reads your comment and it sticks in their brain and saves their life. The other replies were needless and bad attempts at satire.

[@182QKFTW]

Thought we learned a long time ago that ATR's & icing don't mix well. Blue skies

[@jacquesleroux5069]

Great video!

[@sbkbg]

Hopefully the investigation looks into overall company culture. I don't know anything about this airline but that could be a factor if there's poor company culture that the flight crew felt like they had to get to the destination or face punishment.

[@BkNy02]

Just as I expected. Highly trained pilots ignored warnings of the aircraft during severe icing conditions. I guess the in depth investigation starts here to find out why. I'm curious what the other pilots will say during interviews. But I'm more interested in the company's rules and procedures, and were pilots monitored for compliance.

[@user-iq2yp1dn1q]

given the confusion of the number of passengers and earlier reports that many did not make the flight, could there have been a load distribution issue of where passengers were seated and luggage stored, leading to the yaw after the stall instead of a nose down response due to load

[@jeang9467]

Was the airframe de-icing system operative or not? A few minutes after take-off the pilots got a faulty system alert when they turned the de-icing system on, and they commented on this situation and turned it off. Yet, they still turned it on again twice, a couple of minutes before the crash.

[@TOMLINBISH]

So the pilots got into a weather system they shouldn't have even been in & then didn’t take the prompt & appropriate actions that would've prevented this crash from occurring! I find it absolutely shocking that the pilots simply didn’t operate the aircraft properly! 😡

[@NicolaW72]

Indeed.

[@Danger_mouse]

Human factors is my one concern as a FIFO mine worker doing a flight in and out of site each week. Does the cockpit crew have the level of skills required, and the ability to follow the check lists in the event of a problem? I'm not a nervous flyer, but it's a genuine concern for me. The various mining companies all look for the best price to reduce costs, this extends to the flight providers. The current company has many cancelled flights due to aircraft faults, only a matter of time 😢one of these faults is in the air...

[@AviationNut]

So it kind of looks like the pilot's were ignoring all the warnings the aircraft was giving them, but let's wait for the final report to find out completely.

[@meznaric]

It sounds as though they were completely unaware of the developing situation despite warnings. If pressurisation was potentially faulty it's possible they were slightly hypoxic.

[@TakingOff]

That’s interesting, I had not thought about that

[@TrainerAQ]

That's a possibility, but unlikely I believe. Still for that we will need to wait for the full report where they determine why the pilots made the decisions they did

[@wayneschenk5512]

They were fools for sure to ignore the warning signs.

[@AviationAccidentsYouTube]

Good Report

[@blueeyeddevil1]

5:52 “Seven seconds later, the ‘increase speed’ alert went off.” “That means they’re going too slow.” Thanks for that much needed explanation 😉

[@markorr7035]

Summary: Plane tried to save people. Avionics to flight controls interface failed.

[@alalmquist9423]

Hey TEAM TIGGIO Congratulations on the 10K

[@Mal4de]

I might be mistaken, because I am no specialist, but the Prelim Report does state expressly that it was the "Air Conditioning Pack" that was inoperative; They did not say "Pneumatick Pack". They also said that the inoperativeness of the mentioned pack did not affect its deicing capabilities. It might be the same thing, I don't know.

[@TakingOff]

The Prelim report simply states "Pack" under the headline "Pneumatic System". But that is part of the air conditioning.

[@Mal4de]

@@TakingOff Thanks for the clarification. This is a very important system to the unfolding of the final story as to what happened there.

[@vekkuTV]

A classic form of the pilots messed up big time.

[@NicolaW72]

Yes.

[@flyinkiwi01]

It appears they were unable to comprehend that their situation was critical. I’m not sure why. Could be many factors, but a very risk tolerant attitude simply must be on that list. An hour in icing with the de-icing system switched off? Without consideration that loss of aircraft control was a very real possibility? Aircraft have stall speeds, but when the icing system is on, the stall protections will activate at higher speeds - because an iced up wing will stall at much higher speeds than usual. “Cruise speed low” is a bit of a nightmare warning. It strongly suggests that your performance has degraded significantly due to icing and your main option now is to turn altitude into airspeed and descend (ideally into warmer air, below the freezing level) because you don’t have enough power to remain in level flight with an adequate margin above the stall. Request it, if denied insist on it, if denied again; do it and advise ATC. Sort of a “oh just another warning message,” type of approach. If I turn off the icing system then warnings disappear, “problem solved.”

[@feliphebueno2333]

What really puzzles me is how come did the plane goes from 191kt to 169kt in 3 minutes and even after a degraded performance alert no one seems to care about it!? It sounds insane to ignore such an alarming situation.

[@daveroche6522]

AVIATE! NAVIGATE! COMMUNICATE! Remember - "If it flies, it can crash; if it floats, it can sink; if it's electrical, it'll try to kill you (but nothing personal)".

[@scottmoseley5122]

Wow... how can they be so carefree about the icing given the plane's history. Training needs to be modified..

[@carloscortes5570]

Do u guys believe that it would had made a difference if they set thrust to idle? Do u guys think that would had helped slow the spin and lower the nose??

[@TakingOff]

The experts in the ATR I talked to said 99% chance unrecoverable.

[@timhardman4764]

@@TakingOff would the simulator training include spin recovery?

[@StanfordJohnsey]

Generic spin recovery, trust to idle.

[@thomasaltruda]

@@timhardman4764no

[@Mixer-he2wb]

Entering a turn changes stall speed, reducing margins further on an already degraded aircraft. That may be the final hole in the cheese.

[@NicolaW72]

Indeed.

[@johnharris7353]

Won't see me getting aboard an ATR !

[@rexmyers991]

Please don’t blame the ATR. It did everything it could to warn the pilots. It appears improper or inadequate (or a combination of both) is the root cause.

[@barryscott6222]

@@rexmyers991 True. Also, there are a huge number of ATR's flying. Some in area's where icing is almost a constant issue. And yet, these are not crashing all over the place. If it was the plane that was the problem, then there would be many more crashes. Complacency is looking like the culprit here - and that will crash any plane.

[@fredferd965]

A high aspect ratio wing (long, thin wing) has inferior ice carrying capabilities compared to a normal wing. For instance, during WWII, the C-87 cargo plane (a version of the B-24), which had a high aspect ratio wing, was considered to be a lousy ice carrier.

[@jonchowe]

What did they do in those 12 seconds after the stall warning? Assuming ice was already quite built up, would it matter what they did?

[@TakingOff]

Hard to say with the ice buildup, because it’s a TestFlight now. But had they push the nose down and developed more airspeed, maybe they avoid the stall. But that’s a big maybe.

[@timhardman4764]

not a pilot but I believe the heating elements used for de-icing take some time 5 - 10 minutes to do anything and of course that depends on how much ice has accumulated. Since they were on the edge of stalling for a few minutes just before the spin one can assume the plane had A LOT of ice on it that would take awhile to break off with heating elements. However the boots on the leading edge when inflated breaks off the ice immediately....on the boots....that hopefully pull off some more ice on the wings as the boot ice departs. I tend to think they were already doomed 5 - 10 minutes before the stall occurred...non reversible situation at that point. Sad ending and so strange how the pilots had little concern about the deadly conditions they were flying in for so long.

[@tallishyeti2756]

If they would have lowered the nose, they could potentially have exited the stall and then just not have been able to hold altitude. Rather than entering a flat spin and killing everyone.

[@timhardman4764]

@@tallishyeti2756 Possibly....that's what they should have done...change angle of attack and build up some speed to avoid the stall but that itself would not change the load of ice they were hauling around and the shape of the wing that not only had the excess weight but also a new "shape" that was probably not providing much lift. A nose down attitude, with all that weight and reduced lift due to wing shape might have gotten them lower quickly without being in a spin but due to the ice load and quick trip down to ground level I don't think they could have pulled out from the high speed "dive" down and there would not have been enough time in that dive to shed any of the ice. By the time they stalled...and even a few minutes prior they were sadly doomed.

[@tallishyeti2756]

@@timhardman4764 I’m not sure what the height of the terrain was in their location but trading 17,000 feet of altitude for airspeed should have been able to get them so an airport. I

[@marcg1686]

At about 12:49 it's stated that the crew of Flight 4184 followed procedures recommended when encountering icing conditions. This is not true. The plane entered the icing conditions with the auto pilot active. Not allowed. Flaps were set to 15 in the holding pattern. Not allowed.

[@dynasty006-y9e]

ATR issued an update on how their aircraft should be handled on icing conditions after that crash. Those procedures weren't vigent when AE 4184 crashed. Plus, the ATR design design itself was a lot more susceptible to icing induced LOC back then.

[@marcg1686]

@@dynasty006-y9e You're right and I am wrong. An ATR 72 instructor has confirmed what you stated. My bad.

[@1ralton1]

Just to let you know that you seem to have a 60Hz ? Hum present on the audio. It's no terribly loud but it's enough to be distracting / annoying. Perhaps you might want to look into having that removed / solved for future episodes.

[@larryl43]

thank you \

[@arturo468]

Reported elsewhere - the crew requested a lower flight level which was denied by ATC.

[@TakingOff]

That’s not in the CINEPA report

[@major__kong]

I don't think kinetic energy is the right term. For freezing to occur, water needs a seed or nuclei of condensation around which the ice crystal can form. This can be dust or a piece of aluminum skin.

[@agusbahagia5122]

No information whether the autopilot and autothrust were on or off and if it was tripped off upon initial stall warning.

[@user-po3ev7is5w]

I called it exactly the day after the crash. Pilot error regarding handling icing conditions. Modern pilot training seems to be extremely bad.

[@Anonymousones1]

My god the feeling of dropping like that would be freaky. May Jesus Christ of taken them in his arms before the impact 🙏🏻

[@georgemetaxas9227]

I' not a pilot, but I wonder why a deicing system would be turned off, if not well away from an area of potentially icing conditions.

[@TakingOff]

It’s one of the things they’ll be looking at. Did they think the warning was an error?

[@rodolfoayalajr.8589]

Condolences to the families and friends. Thank you friend for sharing this educational horrific tragedy. May they all rip Amen 🙏. Hi from Temple Terrace Florida. 🇺🇸🇵🇷🙏.

[@markorr7035]

There is no excuse for such casual indifference to these warnings. Even if the company did not train you, to ignore warnings of this nature is inexcusable.

[@Xin777]

I am Brazilian, and what the report does not show-although it is still being reported timidly here-is that the pilot was not scheduled for that day and was called in at the last minute to operate the flight. This practice was somewhat common at the company, so it is easy to infer that the stress level was likely higher, and perhaps the pilots did not have enough time or adequate planning for the ice zone they encountered. Despite being traditional and old, this company is small and faces both economic and organizational problems. Also there's a video from an incident happened in Norway shows exactly the same moves that Voepass did before stalling but without losing total control: kzbin.info/www/bejne/g3rPqHiMf72foZosi=ierIMEjtiwQ47FZE And this is the real simulation released by Cenipa, yes, they cut the flatspin part: kzbin.info/www/bejne/eZq2iqVqZbCIbLMsi=VDX1FQqwepynKXYs

[@TakingOff]

Wow, wish i had seen the CENIPA video before posting mine- would’ve have used some of their imagery.

[@barryscott6222]

Why didn't they... ??? show any concern about icing... Sounding like confirmation bias at this point.

[@Wargasm54]

Strange that two seasoned pilots would ignore icing warnings. Especially since the plane was pushing its max ceiling. Senseless really.

[@agauerm]

normalization of deviance

[@garyclarkin2238]

Good job

[@jamesm568]

I was hoping something new popped up and the pilot's reacted to a phenomenon that's never happened before, but in this case it looks like just good ole human error or lack of training.

[@MrDudulex]

If Voepass pilots were so skilled as Cenipa investigators...

[@werquantum]

I’m not a pilot, but it would seem to me that any indication of icing would be just a single step down from out-of-control flight. In other words, treat it like an emergency. Am I wrong?

[@nice2care]

I wonder if the crew thought they were experiencing ICTS and tried to recover by pulling the nose up.

[@Kado_Tornado]

What a shame. A certified pilot does not equal a competent pilot. Depends on the country for sure.

[@agauerm]

Complacency has no nationality

[@MatthijsvanDuin]

Given how _neither_ of the two experienced pilots seemed to have any concern about what was going on, that would seem to suggest the problem lies in training and/or a deficient safety culture in the airline

[@agauerm]

normalization of deviance

[@kingjames8283]

Having seen two prop jobs go down due to icing, it shocks me that pilots don't take this condition more seriously than they do. As ice builds up on the wings and tail plane in straight and level flight while on autopilot, the ailerons, flaps, elevators, and stabilizer become unmovable. By the time this is discovered, it's too late. When the pilot commands a change in speed and/or direction, the flight control surface may break loose for a brief moment but turn around and lock up in the new position and once that happens, the aircraft is gone. Pilots should know before climbing into the cockpit if there will be an icing concern in the flight path and have a plan of action ready before encountering such conditions. Pilots of smaller GA aircraft should forget flying altogether when icing conditions exist as they are most prone to falling victim to control surface icing. Watching the second high performance Pilatus PC-12 aircraft crash into the ground after he initiated a left bank turn and the controls froze in that position, all I could do was watch it unfold. Luckily the pilot was the only soul on board and he died upon impact in the couple of seconds this event occurred so I know in my heart, he didn't suffer. Surely he knew before the flight that icing conditions existed that night yet he decided to fly anyway and just over 50-miles later crashed inverted into the ground when his controls froze up. Thankfully, this was in a cornfield and no one else was involved.

[@rafborrero]

Basically the airplane was screaming that something was wrong and they ignored it