What happened
On March 16, 2018, a Cessna U206F, registration PT-KTI, operated by Piquiatuba Táxi Aéreo Ltda., was performing a commercial flight from Cantá, Roraima, to Oriximiná, Pará. The flight was intended to transport a pilot and one passenger, with a planned intermediate stop for maintenance purposes.
Approximately two hours and twenty minutes into the flight, the aircraft experienced an engine failure. The pilot executed emergency procedures and performed a forced landing (ditching) in the Mapuera River, near Aldeia Tamyuru. The aircraft sustained substantial damage, including impacts to the wings, flaps, ailerons, windshield, nose gear, and propeller. The aircraft remained partially submerged for approximately 46 hours before being recovered. Both occupants emerged uninjured and were assisted by local indigenous residents.
The investigation
CENIPA investigators examined the engine, fuel, and flight path. The Continental 10-5/20-F engine was disassembled by a certified maintenance organization, which found no mechanical deficiencies, improper assembly, or premature wear in the internal components. While the left magneto showed oxidized points, this was attributed to contact with river water during the ditching. Fuel samples from both tanks were found to be compliant with regulatory standards, and no contamination or blockages were identified in the fuel system.
The investigation also analyzed the flight trajectory. Although the flight plan indicated a route via the VOR BVI, the aircraft had deviated significantly to the right to avoid flying over Guiana. The investigation noted that the aircraft eventually ended up 42 NM to the right of its original planned route and 38 NM from its intended deviation path, with no justification provided for why the pilot did not return to the planned route.
Findings
- Flight indiscipline: The pilot failed to return to the planned flight path following a route deviation, violating air traffic regulations.
- Management supervision: There were indications of inadequate managerial oversight within the operator, noted by a pattern of recent significant occurrences and a lack of adherence to safety culture.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to:
- Work with the operator to improve its Safety Management System (SMS), specifically regarding operational planning, management supervision, and safety culture.
- Alert the organization to the risks associated with operating on uncertified or unregistered landing strips.