Report finds failures, omissions in deadly Brazil Voepass crash

A final report into the August 9, 2024, Voepass plane crash that killed 62 people has identified significant operational and maintenance failures, according to official sources. The investigation by the Center for Research and Prevention of Aeronautical Accidents (Cenipa) concluded that the aircraft was operated with an unrecorded de-icing system failure.

Furthermore, the report states that the crew did not execute the correct procedures when the plane issued alerts about performance degradation. Cenipa also determined that the flight should not have taken place due to a malfunction in the right windshield wiper and the forecast of rain during the journey. Lieutenant Colonel Paulo Fróes of Cenipa highlighted an "organizational culture that normalizes practices outside of standards" within the company, characterized by informality and a lack of failure reporting that allowed aircraft to remain in operation.

Contributing factors to the accident included de-icing system failures, exposure to severe icing conditions, coordination issues in the cockpit, inadequate crew decisions, and deficiencies in the company's risk management. The accumulation of ice led to a loss of aircraft performance and contributed to the loss of control. The crew failed to apply proper procedures in response to de-icing system failures and subsequent performance degradation warnings.

Cenipa analyzed 1,206 flights by the aircraft between August 2023 and the accident date, finding that approximately 30% had some type of incident. The agency also pointed to the National Civil Aviation Agency's (ANAC) oversight processes as a contributing factor, deeming them insufficient to identify and control the company's operational vulnerabilities. The crash involved an ATR 72-500 aircraft flying from Cascavel to São Paulo, which crashed in Vinhedo, São Paulo state. All 58 passengers and four crew members perished. Cenipa clarified its investigation is preventive and does not assign civil or criminal liability, though the Federal Police are conducting a separate criminal investigation.