Cenipa points out 19 factors that contributed or may have contributed to the Voepass accident The Center for Research and Prevention of Aeronautical Accidents (Cenipa) pointed out a list of factors that, according to the agency's investigations, contributed to the crash of the Voepass plane in Vinhedo (SP), in an accident that killed 62 people in August 2024. In total, the final report on the tragedy, presented this Thursday (23), cited 19 points, being that 15 of them were identified by Cenipa as motivating the fall. The other four, according to the agency, may also have contributed, but it was not possible to be certain during the investigation. MORE on the windshield wiper that was supposed to prevent it from flying when rain was forecast. Lieutenant Colonel Paulo Mendes Fróes, the investigator in charge of the investigation by Cenipa, said that, after analyzing 1,206 of the company's flights a year before the crash, the agency found that there was a "culture of normalizing deviations" at the airline. In a statement, Voepass stated that the accident was the most serious episode in its history and highlighted that it provided support to the families of the victims from the first moment. The company also reported that it continues to cooperate transparently with the investigations. Anac, in turn, said it will carry out a "detailed" technical analysis of the recommendations presented. See the full notes at the end of the report. Below, see 19 points that Cenipa considered in the report and the explanations for each one: Application of commands (contributed) Attention (contributed) Attitude (contributed) Qualification and training (undetermined) Adverse weather conditions (contributed) Cabin coordination (contributed) Work group culture (contributed) Organizational culture (contributed) Emotional state (undetermined) External influences (undetermined) Piloting judgment (contributed) Aircraft maintenance (contributed) Perception (contributed) Flight planning (contributed) Decision-making process (contributed) Organizational processes (contributed) Project (undetermined) Management supervision (contributed) Anac performance (contributed) Image taken by drone shows the work of emergency teams at the site of the Voepass plane crash in Vinhedo (SP), on August 10, 2024. Carla Carniel/ Reuters Application of commands (contributed) The excerpt means that, when the warning that the plane was losing lift (stall) sounded, the pilots reacted by pulling the aircraft's nose up. Attention (contributed) Matters that were not under the control of the plane caused the crew to lose focus. Because they were talking, they didn't pay enough attention to the ice accumulating outside or to the warnings and alerts that flashed or chimed on the dashboard. This has led to what experts call "inattentional blindness", which is when you look at something, but your brain is so distracted that you don't "see" the danger. Attitude (contributed) Even knowing that the wing ice cleaning system was failing and that the weather forecast indicated severe ice on the way, the pilots planned to continue the trip normally. Instead of looking for alternatives to reduce the risk (such as changing route or altitude), they stuck to the original plan and disregarded the safety rules for that type of situation. This choice caused the plane to fly at a safety level far below what is acceptable, leaving the aircraft vulnerable to ice buildup that hit the crash. Qualification and training (undetermined) Although the pilots completed all mandatory courses and training — including learning how to fly in icing conditions and how to recover the plane in emergency situations — their attitudes during the accident were not what would be expected from trained professionals. Adverse meteorological conditions (contributed) Meteorological conditions contributed to the configuration of the incident scenario, creating an unfavorable environment for the safe operation of the aircraft. Prolonged exposure to severe ice conditions resulted in significantly increased performance impairment. Cabin coordination (contributed) Inadequate management of tasks for each crew member, failure in communication and non-compliance with operational standards characterized inefficiency in cabin coordination, in which risk management was not mitigated jointly, which favored the conduct of the flight in an environment of increasing risk, even in the face of successive alerts. Work group culture (contributed) As alerts from the APM system (aircraft on-board computer) appeared very frequently on a daily basis, pilots ended up getting used to them. This has created what technicians call complacency, which is a type of overconfidence in ignoring repetitive alerts. Organizational culture (contributed) Informality prevailed in the company in interactions between members, between different hierarchical levels and sectors. According to reports, if, on the one hand, this proximity and informality generated a friendly atmosphere, on the other, it opened space for improvisation and permissiveness, leading to the relaxation of rules and the degradation of the flight safety culture. Thus, the collective perceptions of company members reflected mistaken core values ??and low adherence to flight safety principles. The existence of informal rules, informally institutionalized, resulted in the weakening of the security culture. Emotional state (undetermined