Voepass Accident: final report points out that the company, pilots and Anac failed The final report from the Center for Research and Prevention of Aeronautical Accidents (Cenipa) on the crash of the Voepass plane, in Vinhedo (SP), presented defined recommendations to the institutions involved in the tragedy - including ATR, the French manufacturer of the aircraft, and the National Civil Aviation Agency (Anac) - and pointed out conclusions about the air accident. The result of the investigation was presented this Thursday (23) and concluded that failures by Voepass, the pilots and Anac inspection contributed to the crash. In total, 39 items were listed as conclusions of the investigation in the final document. See below a summary of them: Presence of severe icing: the plane encountered meteorological conditions of severe icing during the flight. This occurred during the ascent and persisted throughout the journey; De-icing system failure: the technical failure affected the system responsible for removing ice from the right wing; Disregard of critical warnings: the aircraft's monitoring system issued at least eight low speed warnings and degraded performance alerts, but the pilots did not carry out the emergency procedures provided for these situations; Lack of attention in the cockpit: conversations between pilots about personal matters, unrelated to the flight, took the focus away from monitoring the ice and instruments; Errors in the recovery attempt: when the aircraft lost lift and began to fall (stall), the copilot acted contrary to the manuals, pulling the stick instead of pushing it, which worsened the situation and prevented control recovery; Maintenance and records problems: the ATR 72-500 aircraft was released to fly with a technical failure in the de-icing system that was not recorded in the logbook, which prevented repairs; Lack of safety: Voepass had a culture of "normalizing deviations", in which pilots and mechanics did not report breakdowns in the logbook so that the planes could fly the following day; Insufficient supervision: the report points out that Anac's risk management process was not sufficient to prevent the accident; Details of the crash: the plane went into a flat spin (rotating on its own axis while falling vertically) and completed five turns before colliding with the ground. Speed ??of fall: With the loss of control, the speed of descent was 14 thousand feet per minute, equivalent to a fall of 4 kilometers every minute. Recommendations Cenipa releases final report on factors that led to the crash of the Voepass plane. Gabriella Ramos/g1 Four recommendations were sent to the European Union Aviation Safety Agency (EASA), the body that regulates European air transport, to be passed on to ATR. They are: Change in performance alerts: review the degraded performance procedure so that the alert requires immediate action from the pilots to accelerate the plane and prevent it from falling below the minimum speed; Rules for icy turns: ATR must improve flight rules in icy conditions, to prevent an increase in stall speed (loss of control) caused by the possible lateral inclination of the aircraft in conditions of performance degradation; Improvement in the black box: include the recording of technical data that is currently not recorded, such as failures in the de-icing system, activation of the stall safety system and the position of each pilot's sticks; and Change in the warning system: reevaluate the monitoring system (APM - aircraft performance management, in English) to improve the crew's situational awareness of the severity of the condition encountered and the need to carry out procedures. The report also made recommendations to Anac: Review of checklists: check whether all companies operating the ATR model in Brazil included the speed adjustment procedure during the flight in their manuals; Improved communication: review the communication rules between the plane and the ground teams, so that the exchange of information about dangers is faster and more efficient during the flight; Improving supervision: updating Anac’s internal processes so that surveillance activities can identify risks; Disclosure of the result: sharing the result of this investigation with airlines to increase pilots' awareness of the dangers faced on this flight; and International monitoring: monitor whether the European authority (EASA) will implement the suggested changes to the plane's design. MORE Flight 2283, on August 9, 2024, was the most difficult episode in the history of VOEPASS. From the moment of the accident, the company was in solidarity with the families of the victims, sharing a pain that remains present in their memory. In more than 30 years of operations in Brazilian aviation, the company had never faced a situation like this. Over three decades, it has always adopted serious safety, training and crew guidance procedures. with IOSA certification since 2012, a requirement for operational excellence issued only to IATA audited companies. The crew of flight 2283 was experienced, qualified and duly certified, accumulating more than 5,000 flight hours and with rigorously updated technical training and health monitoring, without any prior registration or factor that prevented their performance.