What happened
On June 18, 2001, an EMB-121 Xingu, registration PT-MBV, operated by JAT Aerotáxi Ltda, was performing a flight from Brasília to Ceres, Goiás. The aircraft was carrying two crew members and four passengers. Upon arriving at the Ceres aerodrome, the crew executed a standard traffic pattern and landed on runway 33.
During the landing roll, the aircraft began to drift to the left. The crew was distracted by a flock of birds flying toward the aircraft and the glare of the sun, which was positioned directly in the aircraft's path. As the aircraft drifted, it struck a termite mound located at the edge of the runway, causing the left main landing gear to collapse. The aircraft continued to veer left, rotating 90 degrees relative to the runway centerline, and came to a stop approximately 120 meters past the point of impact. All occupants evacuated the aircraft without injury, though the aircraft sustained severe damage to the engines, propellers, landing gear, and wings.
The investigation
CENIPA's investigation revealed that the crew was aware that the Ceres aerodrome was unsuitable for the EMB-121 Xingu. The runway width was only 13 meters, whereas the aircraft's manual recommended a minimum of 18 meters, and the runway was only rated for aircraft up to 2,500 kg, while the aircraft's landing weight was approximately 4,500 kg.
Investigators also found that the aerodrome lacked essential safety infrastructure, such as a windsock, which prevented the crew from accurately determining wind direction and intensity. Furthermore, the investigation highlighted organizational deficiencies within the operator, noting a lack of Crew Resource Management (CRM) training and a corporate culture that prioritized mission completion over flight safety.
Findings
- Improper Operational Decision: The pilots proceeded with the landing at an aerodrome that did not meet the technical requirements for the aircraft's weight and width.
- Distraction and Visual Impairment: The sudden appearance of birds and the intense sunlight at the aircraft's nose diverted the pilot's attention and hindered runway visibility.
- Inadequate Infrastructure: The lack of a windsock prevented the crew from identifying a moderate crosswind, and the convex shape of the unpaved runway contributed to the lateral drift.
- Organizational Oversight: The operator's flight operations department failed to provide adequate supervision by scheduling a flight to an incompatible airfield and lacked a robust safety culture.