Hello All aviators!


Voepass was eventually grounded in the wake of the ice-related loss of PS-VPB.

Quite aside from the revelations about Brazilian carrier Voepass's dismal litany of operational failings, prior to its fatal ATR 72 icing-related flat-spin crash, is the puzzlement over why the situation was allowed to persist.

Voepass which emerged in 2019 through the integration of MAP Linhas Aereas
and Passaredo Transportes Aereos might fairly have been described as an accident waiting to happen.

Investigation authority CENIPA referred to the normalisation of deviation
at the airline, the evolution of an informal acceptance of incorrect or non-standard practices, in its probe into the August 2024 crash at Vinhedo.

Among its causes are the existence of a permissive organisational culture, routinisation, and the absence of immediate negative consequences,it says.

If national regulator ANAC failed to take sufficient preventative action against Voepass in the lead-up to the accident, this doesnt appear to have been
down to lack of attention.

Within the inquiry documentation is a graph detailing the number of ANAC queries identified during surveillance actions, per 1,000 take-offs, for the main scheduled operators.

The contrast is striking: over 2,800 for Voepass operators MAP and Passaredo between 2022 and 2024, compared with 160-180 for other airlines.

This was despite Voepass accounting for just 0.6% of scheduled Brazilian network volume.

Over the same period, and prior to the accident, there were 46 instances of precautionary suspensions of Voepass aircraft including 24 during 2023,
eight in April alone. The aircraft lost at Vinhedo (PS-VPB) was not among them.

ANAC ramp inspections and follow-up surveillance revealed technical, procedural
and systemic issues including occurrences at several maintenance bases.

Among these were activities performed without consulting manuals, or without supervision, and improvisation arising from lack of tools. The inquiry also highlights non-compliance with minimum equipment list conditions, and a recurrent practice of informal reporting or non-reporting of malfunctions.

Despite the intense scrutiny and the warning signs which emerged, the scope of ANAC the risk management process was insufficient to rein-in Voepass.

Signs identifying hazards, degradation of technical conditions, and latent conditions prior to the accident were not capable of supporting the strategic decision-making necessary for the mitigation and control of risks in the operational environment regulated [by ANAC], says the inquiry.

The means for recording, processing, and monitoring data and information related to hazards for the purpose of risk management were still in a maturation phase, allowing the continuity of the company operations despite degradation of the safety levels.

This suggests the regulator saw individual problems, but was unable to synthesise them into a clear picture of the broader decline in safety.

It ultimately grounded Voepass and revoked the airline operating
certificate in June last year after the carrier, which was subjected to closer monitoring after the accident, was unable to resolve concerns.

ANAC says safety of air transport is its central mission. It has embarked on a detailed technical analysis of the inquiry recommendations, which include reviewing and updating the risk-management process to help future decision making.


So lots of large words but basically - poor maintenance not using a/c manuals or recommended tooling no supervision for persons not qualified etc.
They do not make any mention of Tech logs but I suspect they also was lacking and judging by some FTO's visited over the last couple of years and the non availability of same with the person on reception wondering why I cancelled bookings and yes this in the UK so took a 378 for a flight or two instead, safer.

Vincent

Source Flight Global Digest.

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