Investigation Summary
The flight was a scheduled passenger service from Belém to Porto Alegre with seven intermediate stops. After departing São Paulo-Congonhas, the aircraft was on its final approach to Florianópolis. At the controls was an inspector from the Civil Aviation Department undergoing training for a supervisory role, overseen by the aircraft commander. The approach was conducted at night during a severe thunderstorm with heavy rain and lightning. After an initial aborted approach and go-around, the crew attempted a second approach. The airport's reliance on an NDB system made navigation vulnerable to electrical interference; lightning strikes generated false position signals, leading the crew to believe they had passed the final approach fix. Consequently, the crew initiated a premature descent to 2,000 feet. Environmental factors, including a strong crosswind and severe turbulence that delayed a turn by 50 seconds, further displaced the aircraft. The Boeing 727 struck the north side of Morro da Virgínia at 20:38 local time, approximately 60 meters below the safety limit for the area.
Final Conclusions
The investigation by SIPAER concluded the primary cause was Controlled Flight Into Terrain (CFIT) resulting from pilot error and environmental factors. Contributing factors included the crew's misjudgment of speed and distance, inadequate flight supervision, a lack of crew coordination, and improper operation of the engines. The failure to initiate a go-around when the second approach became unstable was also cited. The lack of modern navigational infrastructure at Florianópolis and the susceptibility of the NDB to electrical interference during the thunderstorm were critical systemic failures that led the crew to descend prematurely into terrain.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
NDB (Non-Directional Beacon)
The primary navigational aid at the airport, which provided false position readings due to lightning-induced electrical interference.
ADF (Automatic Direction Finder)
The cockpit instrument used to track the NDB signal, which was affected by the severe thunderstorm.
CVR/FDR
Flight recorders recovered on April 14, which showed no mechanical abnormalities with the aircraft prior to impact.
Interesting Facts
- 01The aircraft was a Boeing 727-27C that first flew on August 14, 1966, and was previously operated by Braniff Airways.
- 02The airport at Florianópolis only had NDB navigational aids at the time, which are highly susceptible to weather interference.
- 03The crash site was located approximately 22 to 24 kilometers north of the Hercílio Luz International Airport.
- 04The flight was being operated by an inspector pilot under training for a supervisory role.
- 05The impact occurred at an altitude approximately 60 meters (200 feet) below the safety limit for that specific region.
Safety Actions & Advisories
Navigation Infrastructure Upgrade
Between July 1981 and April 1982, Infraero installed radar, ILS/DME, and VOR systems at Hercílio Luz airport to replace the obsolete NDB.
CINDACTA II Implementation
The Brazilian Air Force accelerated the implementation of the Second Integrated Air Defense and Air Traffic Control Center (CINDACTA II) in November 1982.