Alcuni servizi di manutenzione aeronautica di elevata rilevanza, se non eseguiti correttamente, possono causare gravi problemi, come guasti e difetti. Per questo motivo, le normative aeronautiche richiedono che tali procedure siano classificate come ispezioni obbligatorie. In questi casi, una volta eseguita la manutenzione, questa deve essere verificata da un secondo professionista qualificato, estraneo all'esecuzione del servizio. L'ispezione serve proprio a garantire che tutto sia stato eseguito correttamente.
Ieri il COA di Passaredo (Voepass) è stato revocato da ANAC.
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Anac cassa certificado de operador aéreo da Passaredo, principal empresa do grupo Voepass
Agência interrompeu definitivamente operações após identificar falhas graves e persistentes em sistemas da empresawww.gov.br
A seguito dell'incidente, ANAC aveva iniziato una "sorveglianza" più diretta su Passaredo, e aveva scoperto che alcune azioni di manutenzione che richiedono il "doppio controllo" non erano state eseguite.
Perdonate il Google Translate dal comunicato...
ANAC aveva segnalato questa problematica a Passaredo, ma la mancanza di questi controlli aggiuntivi è stata ripetuta su "altri aerei della flotta e in molte attività di manutenzione".
Non è chiaro se un problema di manutenzione sia stato un fattore contribuente (si dice così?) all'incidente.
Il report finale dell'incidente dovrebbe essere rilasciato quest'anno.
Findings.
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e) the operator had an organizational context with multiple vulnerabilities in its safety culture;
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h) there was a culture of absence of formal recording in the TLB, which prevented the company's technical and operational departments from applying corrective maintenance to aircraft systems;
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j) the aircraft had no record of an Airframe De-Icing system malfunction in the TLB;
k) despite the Airframe De-Icing system malfunction, the aircraft was dispatched without the restrictions imposed by the MEL being recorded;
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p) during the climb, upon crossing approximately FL130, the Electronic Ice Detector indicated ice accumulation;
q) during the accident flight, the aircraft experienced a failure of the Airframe De-Icing system, still during the climb;
r) the Airframe De-Icing system failure was associated with the operation of the right wing boots;
s) the procedures prescribed in the checklist for the Airframe De-Icing system failure were not performed;
t) the Airframe De-Icing system was turned on and off multiple times during the flight;
u) after leveling off at FL170, the Electronic Ice Detector indicated ice accumulation on several occasions and remained activated for a significant portion of the flight;
v) the aircraft experienced a performance degradation due to ice accumulation on its surfaces;
w) the CRUISE SPEED LOW advisory was triggered 8 times during the accident flight;
x) the procedures prescribed for the triggering of the CRUISE SPEED LOW advisory were not executed;
y) the DEGRADED PERFORMANCE alert was triggered once during the flight and occurred 1 minute and 42 seconds before the activation of the Stall Warning System;
z) the procedures prescribed for the triggering of the DEGRADED PERFORMANCE alert were not executed;
aa) the INCREASE SPEED alert was triggered during the turn to the SANPA position and occurred 13 seconds before the activation of the Stall Warning System;
bb) no actions by the flight crew were identified that indicated recognition, awareness, or processing of the APM system advisories/alerts;
cc) the procedures prescribed for the triggering of the INCREASE SPEED alert were not executed;
dd) the AOA values reached the stall warning activation threshold for icing conditions during cruise flight;
ee) the procedures prescribed for stall recovery were not executed;
ff) the AOA values reached the stick pusher activation threshold for icing conditions during cruise flight;
gg) during stick pusher activation, a force in excess of 10 daN was applied to the right control column, in opposition to the stick pusher activation;
hh) the opposing action against the stick pusher direction produced a differential force capable of activating the pitch uncoupling mechanism;
ii) loss of control of the aircraft occurred;
jj) the aircraft entered a flat spin, completing 5 left turns over a period of 68 seconds;
kk) the aircraft exhibited a rate of descent of approximately 14,000 ft/min until it collided with the ground;
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