What happened
On February 22, 2018, an EMB-720D, registration PT-VKR, departed from Flores Aerodrome (SWFN) in Manaus, Brazil, bound for Borba. The flight was carrying two pilots and three passengers. Approximately three minutes after takeoff, the pilot contacted Manaus Approach Control to report an equipment malfunction and requested an immediate return to the departure airfield.
During the return, the pilot indicated an intention to land at the threshold of runway 29. However, the aircraft subsequently lost contact with air traffic control. Witnesses at the aerodrome reported seeing the aircraft fall near the threshold of runway 11. The impact resulted in three fatalities at the scene and one additional death in the hospital, while one passenger survived with serious injuries. The aircraft sustained substantial damage to the wings, engine, propeller, and fuselage.
The investigation
CENIPA's investigation focused on the mechanical state of the aircraft and the crew's performance during the emergency. Investigators examined the engine's powertrain and discovered that a high-voltage coil lock had released, damaging the gear teeth of the left magneto distributor.
Regarding maintenance, the investigation found that the airframe, engine, and propeller logbooks were not up to date. Furthermore, the investigation revealed that the aircraft was operating at a weight at least 123kg above its maximum takeoff weight (MTOW) due to the combined weight of the passengers and fuel on board. The crew's experience was also scrutinized; while both pilots held valid licenses, the pilot in command had only 74 total flight hours and no prior experience with this specific aircraft model, and the copilot was unfamiliar with operating from the right seat.
Findings
- Inadequate flight planning, specifically regarding weight and balance, which placed the aircraft above its maximum takeoff weight.
- An engine malfunction caused by a failure in the left magneto distributor.
- Flawed decision-making during the emergency, specifically the decision to attempt a go-around and change landing thresholds, which aggravated the aircraft's critical condition.
- Inadequate Crew Resource Management (CRM), as the crew had never flown together and lacked a formal definition of onboard roles, hindering their ability to coordinate during the emergency.
- Maintenance record discrepancies, including outdated logbooks and concerns regarding the oversight of maintenance services.