Investigation Summary
The flight was operating a multi-leg domestic route and was on its final approach to Manaus when air traffic control (ATC) instructed the crew to break off the ILS approach to accommodate a priority medical evacuation flight. The aircraft was vectored to the left and instructed to maintain 2,000 feet. Despite confirming this altitude, the crew allowed the aircraft to continue a steady descent. The Cockpit Voice Recorder (CVR) revealed a lack of standardized briefings and call-outs. As the aircraft neared the ground, the Ground Proximity Warning System (GPWS) sounded four times, but the crew offered no corrective response. The aircraft impacted the forest in a wings-level attitude at over 250 knots. The investigation highlighted significant organizational failures at Rico Linhas Aéreas, including unrenewed CRM training and a failure to follow established training programs.
Final Conclusions
The accident was classified as Controlled Flight Into Terrain (CFIT) caused by pilot error. Contributing factors included inadequate cockpit coordination, poor approach planning, and a lack of situational awareness. The crew misreported their altitude to ATC as 2,000 feet when they were actually at 1,300 feet. Organizational deficiencies at the airline, specifically regarding pilot supervision and the failure to conduct mandatory simulator and CRM training, were also cited as critical systemic contributors.
Video Analysis
[ATC] Rico Linhas Aéreas Flight 4815 — Air traffic control recordings and radar reconstruction of the final minutes of Flight 4815 as it was vectored for traffic separation before disappearing from radar.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
First Officer
Systems & Failure Modes
GPWS
The Ground Proximity Warning System functioned correctly, providing four alerts that were ignored by the crew.
Autopilot
Investigators could not rule out a malfunction or improper operation of the autopilot, though no specific failure was confirmed.
CVR / DFDR
Recorders were recovered but heavily damaged; the NTSB successfully read the CVR, but the DFDR was unreadable due to a dirty recording head.
Interesting Facts
- 01The aircraft was manufactured in 1988 and had accumulated 35,988 airframe hours.
- 02The crew misreported their altitude as 2,000 feet when the aircraft was actually at 1,300 feet.
- 03The GPWS alarm sounded four times starting at 400 feet, but the crew did not react.
- 04The impact occurred with the wings level, indicating the pilots were unaware of the impending collision.
- 05The airline had not renewed the crew's CRM training or followed the prescribed simulator training program.
Safety Actions & Advisories
Training Program Enforcement
The investigation emphasized the need for airlines to strictly adhere to Training Programs, including mandatory simulator sessions and LOFT training.
CRM Renewal
Recommendations were made to ensure Cockpit Resource Management (CRM) courses are regularly renewed to maintain crew coordination standards.
Flight Safety Inspection Program
The report recommended the effective application of a Flight Safety Inspection program (PPAA) to identify and address operational and training deficiencies within the airline.