What happened
On June 14, 2017, a Cessna U-206F, registration PT-KGC, operated by Paramazônia Táxi Aéreo, was performing a non-scheduled flight to transport personnel in support of the Indigenous Health Secretariat (SESAI) in Roraima, Brazil. The flight departed from Aeródromo Pouso da Águia toward Caracaraí.
Approximately 45 minutes into the flight, the pilot declared an emergency via radio, reporting a propeller issue. Video footage recorded by a passenger confirmed that the propeller had lost one or more blades during flight. The pilot successfully performed an emergency water landing (ditching) in the Catrimani River, roughly 44km from the intended destination.
The aircraft became semi-submerged. While the passenger managed to swim to the riverbank unharmed, the pilot, who could not swim, required assistance to reach land. An AS350B2 helicopter, registration PR-TOD, arrived to perform a rescue. Using a rope, the rescue crew attempted to pull the pilot from the water to the helicopter's skid. During this maneuver, the pilot slipped through the rope and was swept away by the river current. Although a search was conducted, his body was only recovered two days later, approximately 6km downstream.
The investigation
CENIPA's investigation focused on the mechanical failure of the propeller and the subsequent rescue operation. Investigators noted that the aircraft remained submerged and inaccessible because the operator failed to fulfill the legal obligation to remove the wreckage. This prevented a detailed analysis of the propeller failure.
Regarding the rescue, the investigation found that the pilot of the PR-TOD initiated a specialized rescue operation for which the aircraft was not certified and the crew was not trained. The investigation also identified weaknesses in the operator's maintenance control processes, specifically regarding the tracking of inspection and component installation labels.
Findings
- Flight indiscipline regarding the unauthorized and uncertified rescue attempt.
- Inadequate rescue attempt by a crew not trained or equipped for specialized water extraction.
- Maintenance vulnerabilities in the control of component installation and inspection tags.
- Inability to determine the exact cause of the propeller failure due to the lack of wreckage recovery and the operator's failure to clear the site.