What happened
On June 15, 2019, an ATR-42-320, registration PR-MPN, departed from Eduardo Gomes Airport (SBEG) in Manaus, Brazil, bound for Carauari. The aircraft was operating a scheduled public air transport flight with four crew members and 34 passengers on board. Shortly after takeoff, the aircraft experienced an electrical failure. In response to the malfunction, the crew decided to return to the airport of departure. The aircraft subsequently landed at SBE and sustained substantial damage to the underside of the fuselage, landing gear doors, wheels, and tires because the landing gear remained retracted during the landing. While the four crew members and 32 passengers emerged unharmed, two passengers sustained minor injuries.
The investigation
CENIPA's investigation focused on the sequence of events leading to the gear-up landing and the underlying technical and organizational issues. Investigators examined the aircraft's maintenance history, finding that several components, including the Starter-Generator No. 2 and Static Inverter No. 1, were in use despite being in non-operational condition. The investigation also reviewed the flight crew's training records, noting that the pilot in command had recently completed a shortened initial training program and had previously demonstrated difficulties with manual flight management and aircraft systems. Furthermore, the investigation looked into the operator's management of maintenance outsourcing and the organizational climate during a period of company transition.
Findings
- The landing with the landing gear retracted was primarily driven by a premature decision-making process where the crew returned to the airport without analyzing alternatives or executing the Quick Reference Handbook (QRH) checklists.
- Inadequate Crew Resource Management (CRM) led to a failure in task division and a lack of communication regarding the technical aspects of the electrical failure.
- The crew exhibited "tunnel vision" or selective perception, failing to recognize the actual position of the landing gear during the return approach.
- Maintenance inadequacies were identified, specifically the use of faulty electrical components and insufficient oversight of outsourced maintenance services.
- Organizational factors, including an uncertain corporate climate and a lack of formal communication during a management transition, may have degraded operational safety.