What happened
On March 31, 2008, an NE-821 Carajá, registration PT-VCI, was performing a cargo flight transporting bank documents from Salvador to Lençóis, Bahia. While executing an approach under instrument flight rules (IFR), the aircraft entered a left-hand base turn at a low altitude. During this maneuver, the aircraft struck the ground, resulting in the fatalities of both crew members and the total destruction of the aircraft.
As the aircraft approached the runway, the crew noted that the cloud ceiling was significantly lower than the reported 1,20 and that vertical visibility was nearly zero. The pilots had implemented an improvised IFR procedure using GPS, as the local aerodrome did not have a published instrument approach chart and operated under visual flight rules (VFR). During the descent, the cockpit voice recorder (CVR) captured the aircraft's stall alarm sounding, followed by an attempt to apply maximum power before the impact.
The investigation
The CENIPA investigation focused on the flight's descent and the crew's decision-making. Investigators analyzed the CVR, which revealed that the pilot in command managed all communications and checklists, leaving little room for the co-pilot to intervene. The investigation also examined the meteorological conditions, noting a discrepancy between the reported ceiling and the actual conditions encountered by the crew. Furthermore, the investigation reviewed the organizational aspects of the operator, Aero Táxi Abaeté Ltda., specifically regarding Crew Resource Management (CRM) and flight discipline.
Findings
- Flight indiscipline: The pilot in command proceeded with an approach at an aerodrome that only supported VFR operations while the ceiling was below the required minimums, violating air traffic regulations.
- Improvised procedures: The crew utilized an unapproved, improvised IFR approach procedure based on GPS navigation.
- Poor pilot judgment: The commander decided that an improvised procedure would be sufficient to complete the landing despite the lack of official procedures.
- CRM failures: The pilot in command did not allow the co-pilot to perform essential cockpit duties, and the company failed to effectively monitor the implementation of CRM training in daily operations.
Safety action
Following the investigation, several safety recommendations were issued by SERIPA II and CENIPA, including:
- Requirements for air taxi operators to train pilots on the risks of unapproved IFR procedures.
- Implementation of psychological monitoring and CRM training for flight crews.
- Strengthening of risk management and decision-making training for small aircraft operators.
- Audits of operator training programs to ensure compliance with operational manuals.