What happened
On April 12, 2010, a Beechcraft 58, registration PT-WTT, departed from Ourilândia do Norte, Pará, to transport two passengers to the Kendjan Village. During the approach to the landing site, the aircraft touched down approximately 50 meters before the intended landing area. Following the initial contact with the ground, the landing gear was retracted, causing the propeller blades to strike the terrain. The aircraft sustained significant damage to the landing gear, propeller, and the right flap, though all four occupants—two pilots and two passengers—remained uninjured.
The investigation
CENIPA's investigation revealed several critical organizational and operational deficiencies within the operator, FUNAI. The investigation established that the landing site was an unregistered and uncertified gravel strip. Furthermore, the investigation found that the pilot in command was operating with expired technical ratings and an expired medical certificate. The aircraft's windshield was also noted to be heavily crystallized, which could have impacted visibility.
Organizational findings highlighted that the operator lacked a structured training program and a dedicated flight coordination sector. The investigation noted that the flight planning was inadequate, as the crew intended to use an uncertified landing strip without sufficient knowledge of the field's physical characteristics. Additionally, the operator relied on "collaborator" pilots rather than permanent staff, and lacked a system to verify the recent experience and qualifications of the crew members.
Findings
- Inadequate flight planning, as the crew planned to operate on an unregistered and uncertified landing strip.
- Lack of managerial oversight regarding pilot qualifications, with the pilot in command operating with expired medical and technical certifications.
- Organizational deficiencies within the operator, including the absence of a flight coordination sector and a lack of Crew Resource Management (CRM) training.
- Inadequate pilot selection processes, characterized by the use of external collaborators without proper verification of their recent flight experience or specific aircraft type ratings.
Safety action
Following the investigation, several safety recommendations were issued to FUNAI, including the establishment of a qualified flight coordination sector, the implementation of a system to monitor pilot certificate validity, and the requirement to operate only from certified or registered runways. CENIPA also recommended that ANAC perform a safety audit of the organization's operations.