What happened
On October 3, 2002, an EMB-721C aircraft, registration PT-EBK, departed from the São Gabriel da Cachoeira airfield (SBUA) in Amazonas, Brazil, bound for Taraquá. The mission involved transporting three university students and several electronic voting machines for the upcoming regional elections. Shortly after takeoff, the aircraft disappeared from radio contact. The wreckage was located four days later, approximately 2.5 km from the end of runway 23.
The aircraft struck obstacles during the takeoff phase and impacted the adjacent forest. The impact caused the aircraft to slide approximately 50 meters before coming to a complete stop. The crash resulted in four fatalities and the total loss of the aircraft.
The investigation
CENIPA investigators discovered that the aircraft had undergone significant unauthorized structural modifications. The rear cabin divider had been removed and replaced with metal plates to create a makeshift floor for increased cargo capacity. These modifications were performed without technical approval or oversight from aviation authorities.
Furthermore, the investigation revealed serious discrepancies in maintenance records. There were doubts regarding the veracity of previous maintenance logs, as an annual inspection was recorded in the aircraft's logbook on a date after the aircraft had already gone missing. The investigation also found that the aircraft was being operated for commercial purposes despite being registered for Private Air Services (TPP), and that the loading process was handled by unqualified personnel under the pilot's supervision.
Findings
- The aircraft was operated significantly over its maximum takeoff weight, exceeding the limit by 223.51 kg.
- The Center of Gravity (CG) was outside of permissible limits, positioned 0.074 m beyond the rear limit.
- The cargo was distributed throughout the cabin rather than being confined to the baggage compartment, further destabilizing the aircraft.
- The pilot's decision to proceed with takeoff despite the obvious performance degradation and weight excess was a primary contributing factor.
- Operational failures included deficient supervision by the owner and the air taxi company, as well as improper mission planning.
- Psychological factors, including complacency, overconfidence, and pressure to complete the mission, influenced the crew's decision-making.