By Gabriel Araujo and Ricardo Brito
SAO PAULO/BRASILIA, July 23 (Reuters) - Brazilian air accident investigators said on Thursday that a buildup of ice, failures in the aircraft's de-icing system, crew actions and deficiencies at regional airline Voepass contributed to the 2024 crash of an ATR turboprop that killed all 62 people on board.
Voepass Flight 2283 crashed on August 9, 2024, in the town of Vinhedo, about 80 km (50 miles) northwest of Sao Paulo, capturing global attention after images of the plane's
last moments in a stalled "flat spin," rotating more like a falling leaf than diving toward the ground, circulated on social media.
The ATR 72-500 had departed from Cascavel, in southern Brazil, and was headed to Sao Paulo's Guarulhos international airport when it swirled out of control and plunged to the ground.
The final report into the accident released by Brazil's Center for Investigation and Prevention of Aeronautical Accidents (Cenipa) found the aircraft encountered conditions favorable to severe icing and the plane's de-icing system experienced multiple failures, and the pilots switched it on and off several times amid icing warnings.
A total of 19 factors contributed to the crash, Lieutenant Colonel Paulo Mendes Froes told reporters, including the crew's emotional state, external influences, adverse weather conditions and insufficient regulatory oversight.
A preliminary report released in 2024 had identified signs of ice buildup on the aircraft but did not determine a definitive cause for the accident, as safety experts say air crashes are generally caused by a cocktail of factors.
ATR 72 planes had previously been involved in other cases globally where pilots lost control after ice buildup.
Cenipa issued a recommendation to the European Union Aviation Safety Agency (EASA), urging it to work with ATR to review the "degraded performance" procedure to help prevent crews from reaching similar limit conditions in future flights.
ATR, the aircraft's manufacturer, is a joint venture between Europe's Airbus and Italy's Leonardo.
ATR and EASA did not immediately respond to requests for comment.
Voepass filed for bankruptcy protection in April 2025, a month after Brazilian aviation regulator ANAC suspended its operations citing safety concerns.
'INATTENTIONAL BLINDNESS'
The report said the pilots did not carry out required procedures after eight "cruise speed low" warnings sounded during the flight, and failed to take appropriate action after a "degraded performance" alert, despite commenting on the amount of ice accumulating on the aircraft.
Cockpit recordings showed the captain saying that the de-icing system was malfunctioning, the report said, while the first officer stated at one point that he had forgotten to activate the system.
Cenipa said the pilots may have been affected by phenomena known as "inattentional blindness" and "inattentional deafness," in which a high workload can cause operators to miss critical information.
CULTURE OF INFORMALITY
Beyond the flight itself, the report pointed to broader shortcomings at Voepass, describing what investigators called a "normalization of deviations" within the airline.
Cenipa said previous failures involving the aircraft's de-icing system were not properly recorded in maintenance logs and cited evidence that some maintenance tasks were performed without appropriate supervision.
"This stemmed from a culture of informality in which pilots and mechanics did not record aircraft-related issues in maintenance logs, with the aim of allowing the aircraft to continue operating the next day," Froes said.
Cenipa also said the aircraft involved in the crash should not have been dispatched at the time of departure because of a fault in a windshield wiper system, though it added that did not contribute directly to the accident.
Regulator ANAC said it would begin a detailed technical analysis of the report's findings and of the recommendations related to matters under its jurisdiction, in a review expected to take up to 120 days.
(Reporting by Gabriel Araujo in Sao Paulo and Ricardo Brito in Brasilia; Editing by Jamie Freed)
