What happened
On July 5, 2014, a Cessna C208 Amphibian, registration PT-WRU, was performing a chartered flight from Manaus to Boa Vista do Ramos, Amazonas. The flight, operated by Rico Táxi Aéreo LTDA, was transporting six passengers and two crew members to a local community. During the flight, the crew altered the planned landing site from a known river location to Lago Mocambo following a request from a passenger.
As the aircraft performed a water landing on the lake, the pilot attempted to maneuver the aircraft to avoid a rural electrical power line crossing the path of travel. During this corrective maneuver, the left wing of the C208 struck a partially submerged utility pole. The impact caused substantial damage to the left wing and the central fuselage structure, and broke a side window. Despite the impact, the aircraft remained buoyant, and all eight occupants escaped without injury.
The investigation
CENIPA's investigation focused on the decision-making process regarding the change of landing site and the identification of hazards. Investigators noted that during the July season, rising water levels in the Amazon region can create optical illusions, making it difficult for pilots to accurately judge the width and depth of bodies of water or identify submerged obstacles.
While the crew performed a low pass to inspect the surface, the investigation established that the assessment of the landing site was inadequate regarding the presence of obstacles. Furthermore, the investigation examined the organizational culture of the operator, noting that the company provided pilots with high levels of autonomy and lacked specific guidelines to prevent unauthorized changes to flight plans established by the operations department.
Findings
- Inadequate hazard assessment: The crew failed to properly identify the presence of the submerged pole during their approach.
- Risk management failure: The decision to deviate from a known, planned landing site to an unfamiliar location contributed to the accident.
- Organizational culture: The operator's flexible and informal operational rules allowed for deviations from the flight plan without administrative repercussions, which may have influenced the crew's decision to accommodate the passenger's request.
- Environmental factors: Seasonal flooding in the region obscured the visibility of submerged hazards.