What happened
On August 17, 2004, an EMB-201A aircraft, registration PT-GXS, departed from Usina Guaxuma, Alagoas, destined for the Manduca Leão aerodrome in Rio Largo. The flight was a routine repositioning mission to transport the aircraft to a maintenance facility.
Approximately 15 minutes into the flight, the pilot observed that weather conditions were deteriorating, making a visual approach to the destination impossible. The pilot attempted to return to a different landing site at Caeté, but worsening weather prevented a safe return. Seeking to wait out the weather, the pilot decided to fly along the coastline near Barra de São Miguel. As the cloud ceiling dropped to 150 feet and visibility became severely restricted due to rain, the pilot elected to perform an emergency landing on the beach. During the landing attempt, the pilot failed to notice an uneven patch of sand, causing the left main landing gear to collapse and the aircraft to capsize.
The investigation
CENIPA's investigation focused on the pilot's decision-making and the lack of operational oversight. Investigators found that the pilot was highly experienced in agricultural aviation but was not wearing prescribed corrective lenses at the time of the accident, which likely hindered the detection of the terrain irregularity. The aircraft was not equipped with a radio or transponder, preventing the pilot from receiving updated weather updates from air traffic control. Furthermore, the investigation noted a lack of organizational supervision, as the operator did not have specific oversight for flight planning or monitoring the movement of aircraft between agricultural sites.
Findings
- Inadequate flight planning, as the pilot failed to account for the weather conditions along the route and at the destination.
- Improper decision-making regarding the choice of an emergency landing site and the decision to continue flying despite deteriorating visibility.
- Lack of situational awareness due to the pilot's failure to use corrective lenses and the absence of communication equipment to receive weather updates.
- Inadequate managerial supervision regarding the monitoring of flight operations and the implementation of safety procedures.
- Adverse meteorological conditions, specifically low visibility and a low cloud ceiling caused by rain.