Investigation Summary
The flight departed Macaé at 17:19 local time, initially operating under Instrument Flight Rules (IFR). Shortly after takeoff, the crew requested to cancel their IFR flight plan to continue under Visual Flight Rules (VFR) at FL45 (4,500 feet), a request that was approved by air traffic control. As the aircraft approached Rio Bonito, weather conditions were poor with limited visibility. Despite these conditions, the crew requested and was cleared to descend to 2,000 feet to avoid weather, which was below the safe limit for the mountainous terrain in the area. The aircraft was in a left-hand bank when it impacted the summit of Pico da Pedra Bonita at approximately 1,920 feet. The CENIPA investigation highlighted that the crew had not properly reviewed weather data before departure and lacked the training necessary to make sound operational decisions in marginal weather, leading to the fatal descent into terrain.
Final Conclusions
The investigation by CENIPA, concluded on 19 March 2007, attributed the accident to pilot error and poor decision-making. The primary cause was the crew's decision to transition from IFR to VFR in weather conditions that did not permit visual navigation. Contributing factors included a complacent organizational culture within the airline that failed to inhibit unsafe low-altitude flight practices, and the captain's over-confidence due to his familiarity with the region and his status as an instructor captain. The lack of adequate pre-flight weather analysis and flight indiscipline regarding VFR minimums resulted in the aircraft being flown at an unsafe altitude for the region's topography.
Video Analysis
BATEU na SERRA - TODOS morreram — A detailed look at the crash of TEAM Linhas Aéreas Flight 6865, which struck a mountain in Rio Bonito while flying under VFR in poor weather.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Systems & Failure Modes
Visual Flight Rules (VFR)
A set of regulations under which a pilot operates an aircraft in weather conditions generally clear enough to allow the pilot to see where the aircraft is going. The crew's decision to use VFR in low visibility was a primary factor in the crash.
Instrument Flight Rules (IFR)
Regulations that allow for flight in poor visibility by relying on instruments and ATC direction. The crew abandoned this safer flight plan shortly after takeoff.
Interesting Facts
- 01The aircraft was a Let L-410 Turbolet carrying 17 passengers and 2 crew members.
- 02The crew intentionally switched from IFR to VFR despite approaching poor weather conditions.
- 03The impact occurred at an altitude of approximately 2,000 feet on a mountain peak.
- 04CENIPA investigators found the crew had not checked weather conditions prior to the flight.
- 05The final report was released approximately one year after the accident on 19 March 2007.
Safety Actions & Advisories
Crew Training Improvements
The investigation recommended improvements in pilot training regarding decision-making and the strict adherence to VFR minimums in mountainous terrain.