What happened
On February 7, 2009, an EMB 110P1, registration PT-SEA, operated by Manaus Aerotáxi Ltda., crashed into the Manacapuru River in the state of Amazonas. The aircraft had departed from Coari (SWKO) for a charter flight to Eduardo Gomes (SBEG) with 26 passengers on board.
During the flight, the crew contacted Area Control Center (ACC-AZ) at 13:15 UTC, stating they were at FL 115 and descending toward their destination. The pilot subsequently informed Manaus Approach (APP-MN) of an intention to return to Coari. Shortly thereafter, the aircraft lost radar contact. The aircraft struck the surface of the Manacary River approximately 39.5 NM southwest of Eduardo Gomes and submerged. The accident resulted in 22 fatalities among the passengers and 2 fatalities among the crew, while four passengers managed to escape the wreckage and survive.
The investigation
CENIPA's investigation focused on the sequence of events leading to the engine failure and the operational conditions of the flight. Investigators examined the aircraft's maintenance history, noting that during a previous landing at Eduardo Gomes on the same day, the aircraft had touched down off the paved surface, though no immediate discrepancies were reported by the crew.
The investigation also scrutinized the fuel management and weight/balance of the aircraft. It was determined that the aircraft had been refueled with instructions that led to a specific fuel load for the leg, but the investigation highlighted significant deviations in operational procedures. Investigators also looked into the technical condition of the engine components, specifically the fuel heater.
Findings
- Engine failure due to a failure in the thermal element of the fuel heater.
- The aircraft was operating with excess weight and passenger numbers.
- Lack of adequate oversight at the Coari aerodrome allowed the aircraft to depart with weight and passenger limits exceeded.
- The operator failed to enforce its own General Operations Manual (MGO) and manufacturer limitations.
- Potential manufacturing or handling defects in the fuel heater's thermal element.
- Inadequate communication between the company's commercial and operational sectors regarding flight planning.