Voepass flight report says co-pilot acted against safety system

The final report by Cenipa (Aeronautical Accident Investigation and Prevention Center) on the Voepass aircraft accident concluded that the co-pilot, who was in control during the final moments of the flight, applied inputs contrary to the automatic protection system, contributing to the worsening loss of control of the aircraft, which crashed in Vinhedo (SP) in August 2024.

According to the investigation, when the anti-stall system automatically pushed the control column forward to restore the aircraft's lift capacity, the co-pilot applied force in the opposite direction, pulling the control back.

The conflict between the crew member's input and the automatic system is believed to have triggered the elevator decoupling mechanism, causing the control surfaces to operate independently and irreversibly worsening the loss of control.

The report, released on Thursday (23), concludes that the accident was the result of a combination of operational, technical and organizational factors. In addition to the crew's actions in the final moments of the flight, Cenipa points to failures in Voepass's maintenance management, concealment of the severity of damage sustained by the aircraft months before the crash, and deficiencies in oversight by Anac (National Civil Aviation Agency).

Another moment considered decisive by the investigation occurred a few seconds before the loss of control. Four seconds after the aircraft issued an alert indicating performance degradation, the pilots switched off the wing de-icing system.

According to Cenipa, the crew mistakenly interpreted the warning as yet another recurring malfunction of the equipment rather than as an alert that the aircraft was accumulating ice at a critical level and losing lift.

The report states that this perception was influenced by the history of de-icing system failures in other operations by the airline, which led the pilots to associate the audible warning with a known defect, rather than recognizing that the aircraft was facing a severe ice accumulation condition.

The investigation also revealed that the ATR-72, registration PS-VPB, had suffered a tail strike on landing in Salvador in March 2024, approximately five months before the accident. Although the episode was initially treated as a minor incident, Cenipa concluded that the structural damage was significantly more extensive than what had been reported at the time.

High-complexity repairs were carried out without the investigating body being notified of the true extent of the damage.

The document also includes criticism of Anac's conduct. According to Cenipa, audits carried out before the accident had already identified systemic non-conformities at Voepass, including failures in maintenance procedures, improper use of manuals and deficiencies in operational safety management.

Even in the face of these warning signs, the agency's risk management was unable to translate the alerts into strategic decisions that would reduce the risks associated with the airline's operations, the report states.

Voepass Flight 2283 departed Cascavel (PR) bound for Guarulhos (SP) on August 9, 2024. During the cruise phase, the aircraft encountered severe icing conditions, entered a stall and crashed onto a residential condominium in Vinhedo. All 62 people on board — 58 passengers and four crew members — died.

Cenipa emphasizes that the investigation is exclusively preventive in nature and seeks to identify contributing factors to prevent new accidents, without assigning civil or criminal liability.

What Voepass says

In a statement, Voepass says that the crash of flight 2283 was the most difficult episode in its history. "From the moment of the accident, the company has stood in solidarity with the victims' families, sharing a pain that remains present in its memory."

The company continues to assert that, in more than 30 years of operations in Brazilian aviation, it had never faced a situation like this and had always adopted serious safety procedures, training and crew guidance.

According to the company, the crew of flight 2283 was experienced, qualified and properly certified, having accumulated more than 5,000 flight hours and with technical training and health monitoring rigorously up to date, with no prior record or factor that would have prevented them from performing their duties.

"Since the beginning of the investigations, Voepass has been acting transparently alongside Cenipa and public authorities and remains available to all institutions and agents involved to collaborate with whatever may be necessary," the statement concludes.

What Anac says

In a statement to the press, Anac said it will analyze the recommendations presented by Cenipa and will deliver, within 120 days, a technical analysis of what was presented as it pertains to the agency.

"The investigations conducted by Cenipa are exclusively preventive in nature and are not intended to assign blame or liability, but to identify factors that contributed to the accident and to make recommendations to improve the operational safety system of civil aviation," the statement reads.