What happened
On September 5, 2005, an EMB 711, registration PT-NEB, was performing an improvised aeromedical transport from Juína to Sinop, Mato Grosso. The flight was carrying the pilot, three adults, and two newborns, who were being moved to a hospital in Cuiabá. The flight departed in the late afternoon under visibility-reducing conditions caused by dry haze and smoke from regional wildfires.
As the flight progressed into the night, the pilot contacted the aircraft owner at the destination to request that car headlights be turned on to assist with the landing, as the Sinop aerodrome was not equipped for night operations. While attempting to locate the runway, the aircraft struck the canopy of a tree, leading to an unavoidable forced landing in dense vegetation. The impact caused severe damage to the aircraft' and resulted in two fatalities—the pilot and one newborn—while the remaining four passengers sustained serious injuries.
The investigation
CENIPA's investigation revealed that the operation was highly irregular and lacked proper oversight. The aircraft had been modified for the mission by removing passenger seats to accommodate the medical transport, leaving passengers and infants without proper seating or restraints. The newborns were being transported in heated bassinets that were not secured to the airframe.
The investigation established that the pilot was flying under visual flight rules (VFR) despite conditions that necessitated instrument flight capabilities, which he was not qualified for at the time due to an expired instrument rating. Furthermore, the pilot's decision-making was compromised by the need to navigate through smoke, haze, and recent rain formations, which led him to fly at extremely low altitudes to maintain visual contact with the ground.
Findings
- Improvised Aeromedical Operation: The flight was an unauthorized medical transport using an aircraft not equipped or certified for aeromedical services.
- Inadequate Safety Equipment: The removal of seats and lack of seatbelts for passengers significantly increased the risk of injury during the impact.
- Poor Decision-Making: The pilot attempted a night landing at a non-operational airfield using car headlights as a makeshift visual aid.
- Environmental Factors: Heavy smoke, dry haze, and localized turbulence caused the pilot to lose situational awareness and descend to a dangerously low altitude.
- Lack of Supervision: There was an absence of regulatory oversight regarding both the flight activity and the medical transport standards.
- Improper Navigation: The pilot's attempt to fly at tree-top level to find the runway directly contributed to the collision with an obstacle.