What happened
On June 11, 2002, an EMB-810C operated by Oliveira e Silva Táxi-Aéreo was performing a landing approach near Vila Rica, Mato Grosso, when the crew encountered an engine failure. During the final approach, the pilot attempted to extend the landing gear but received no positive indication that the gear was locked down. Consequently, the pilot decided to execute a go-around.
During the single-engine go-around, the aircraft experienced a significant left yaw, making control difficult. While attempting to maneuver away from a tree at a low altitude, the left wing struck a concrete fence. The impact caused the left wing to separate from the fuselage, sending the aircraft into a 180-degree spin before it came to rest in a ditch. The aircraft caught fire upon impact and was destroyed.
The investigation
CENIPA's investigation focused on the sequence of events following the engine failure and the crew's decision-making process. Investigators examined the aircraft's maintenance history, noting that while records were up to date, there were suspicions regarding improper maintenance of the fuel system. The investigation also looked into the company's organizational structure, finding a history of regulatory non-compliance, including operating with expired insurance and performing maintenance at unapproved locations.
Investigators also analyzed the crew's experience and cockpit dynamics. While the pilot was highly experienced in general aviation, he had very limited hours specifically in the EMB-810C. Furthermore, the investigation highlighted a lack of effective Crew Resource Management (CRM), as the co-pilot did not actively assist the commander during the emergency.
Findings
- The pilot failed to retract the flaps during the go-around, which increased drag and negatively impacted the aircraft's performance.
- The pilot's decision-making was influenced by habitual behaviors from previous aircraft types, leading him to incorrectly assume the EMB-810C would perform similarly to other aircraft he had flown.
- The co-pilot demonstrated a complacent attitude, failing to provide necessary assistance or challenge the commander's decisions due to the power imbalance within the company hierarchy.
- The crew had very low experience in this specific aircraft model, with only 90 and 78 hours respectively.
- Organizational deficiencies within the operator included inadequate training programs and a lack of supervision regarding fuel quality during external refueling.