LYON—All 62 occupants of a Voepass Linhas Aereas-operated ATR 72-500 died on Aug. 9, 2024, because of reckless behavior by the carrier’s managers, maintenance technicians and pilots, Brazil’s air accident investigation bureau has determined.
In its final report on the accident, Brazil’s Aeronautical Accidents Investigation and Prevention Center (CENIPA) found abundant evidence of safety lapses within the company, which it described as contrary to the safety standards upheld by the air transport industry.
Brazil’s national civil aviation agency (ANAC) suspended Voepass’ operations in March 2025, after it noted persistent problems at the regional turboprop operator. ANAC permanently revoked Voepass’ air operator certificate in June 2025. CENIPA’s recommendations target ANAC, as the supervising body for air transport in Brazil, and the European Union Aviation Safety Agency (EASA), and suggests improvements to ATR aircraft.
The final report says the crew knowingly flew the aircraft into severe icing conditions, although it was not certified for such circumstances and the airframe deicing system was inoperative. The resulting ice accretion increased drag, triggered alerts and eventually caused a stall. Voepass Flight 2283 originated in Cascavel, in the state of Parana, and was bound for Guarulhos, in the state of Sao Paulo. The crash took place in Vinhedo, in Sao Paulo state. None of the four crew members or 58 passengers survived.
The report describes the widespread violations of safety rules and common-sense obligations in maintenance activities as “jaw-dropping” for a company that operated 15 commercial turboprops.
“At some secondary bases, limitations in maintenance resources were identified, as well as ... restrictions on access to the aerodrome apron due to the lack of airport credentials,” CENIPA says, noting the mechanics had only a few hours, usually during the night-shift period, to perform corrective and preventive maintenance on the aircraft.
CENIPA says technicians performed maintenance in a superficial manner, without completing the required documentation and delegating critical activities to assistants without proper oversight. Some of them did not have the right qualifications to understand a manual’s content, the report says.
Standard Practices
Aircraft may be dispatched with inoperative systems, as long as they comply with their minimum equipment list (MEL). CENIPA points out that at Voepass, this was standard practice, not the exception, adding that some malfunctions were recorded as resolved, without the corrective action being performed.
“There was also the practice of replacing an inoperative component with another known to be malfunctioning and dispatching the aircraft for flight,” CENIPA’s investigators said. “As a consequence, a new malfunction entry would be recorded on the subsequent flight, allowing a new dispatch based on the MEL.”
The investigation found deficiencies in flight crew and managerial behaviors in which pilots routinely did not report malfunctions in the technical logbook, a deviation encouraged by the company. That was the case with the accident aircraft’s airframe deicing system, the investigators noted. Pilots and maintenance technicians just communicated verbally—another aspect of an organizational culture the investigators describe as permissive.
Between 2022-24, ANAC issued notices of irregular condition to Voepass and suspended several aircraft from flight. CENIPA investigators determined ANAC’s risk management process was insufficient for the strategic decisions that would have been necessary, and the agency’s report recommends a revision of ANAC’s methods.
The CENIPA report also says Voepass’ managers, including those in charge of safety, failed to use flight data monitoring. The ATR 72’s aircraft performance monitoring (APM) system issues three levels of advisories when it detects the effects of icing: Cruise Speed Low, Degraded Performance and Increase Speed. Those alerts indicate a performance degradation due to ice accumulation on the aircraft’s surfaces. CENIPA compared Voepass’ data with that of five other ATR 72 operators and found Voepass had significantly more frequent occurrences of such alerts than its counterparts. Pilots did not always activate protection systems after ice was detected, they add.
The day before the crash, the aircraft’s airframe deicing system malfunctioned and the crew attempted three resets, without success. “After the first system reset and the occurrence of a new failure, the flight crew should have followed the deicing airframe fault procedure, which instructed the crew to exit icing conditions, avoid them and turn off the system,” CENIPA investigators said. The pilots informed the maintenance team verbally, which did not check or repair the system.
Accident Sequence
The system failed again on the day of the accident, during the two flights that preceded the accident. Fault messages were displayed accordingly. The crews, including the one operating the accident flight, did not follow the deicing airframe fault procedure. Faced with speed alerts (Degraded Performance and Increase Speed), the crew who would later operate the accident flight only requested a descent to FL140 (approximately 14,000 ft.), from FL160. Air traffic control approved the request, and the speed alert warnings eventually disappeared. The crew’s response, however, did not comply with the standard procedure, which includes increasing airspeed, the report says.
Before the accident, the flight crew and Voepass’ operations control center had access to a weather forecast of severe icing along the planned flight route. They took off despite the predicted conditions and the airframe deicing system’s known malfunction, which stemmed from the right wing boots. During the climb, crossing FL130, the aircraft’s electronic ice detector indicated ice accumulation. The pilots did not follow the prescribed procedures for the deicing system’s fault or the three successive speed alerts from the APM system. The recommendation was to exit the likely severe icing conditions immediately, since aircraft performance and maneuverability would be severely affected after only a few minutes of exposure. After a stall warning, the crew did not follow the stall recovery procedure and lost control.
ATR Improvements
CENIPA recommends that EASA engage with ATR and consider an improvement in the Degraded Performance speed alert procedure. Speed should be increased by a greater margin above the minimum maneuvering speed in icing conditions. Moreover, ATR could extend the use of the Low Bank mode, which prevents the increase in stall speed due to aircraft bank angle, the investigators suggest. The flight data recorder should register more parameters, including deicing system failure. The Increase Speed alert should be upgraded to a Warning message, up from Caution, the investigators add.
Since the accident, ATR has designed a new version of the APM system software, which EASA certified in June 2025. Speed alerts are now based on the airspeed margins relative to the minimum maneuvering speed in icing conditions, rather than the theoretical airspeed values, CENIPA says. In a simulation, the last Degraded Performance alert was activated 31 seconds earlier than in the accident flight.