What happened
On October 17, 2017, a Cessna 208 Amphibian, registration PR-MPE, was performing a flight from Eduardo Gomes Aerodrome in Manaus to the Anavilhanas Fluvial Archipelago to transport cargo and personnel. During the flight, the aircraft attempted to ditch on the Rio Negro.
Upon contact with the water, the aircraft struck the surface with its landing gear extended. The impact caused the floats to break away from the fuselage, leading the aircraft to overturn and settle upside down in the river. The accident resulted in one fatality among the passengers, while the pilot and the remaining three passengers sustained minor injuries. The aircraft sustained substantial damage, including engine mount breakage and engine impact against the cabin structure.
The investigation
CENIPA's investigation focused on the aircraft configuration and the pilot's operational procedures. Investigators found that the landing gear was in the down position during the water landing, despite the control being set to the "UP WATER" position.
Technical analysis revealed that the landing gear position warning system had been programmed to an airspeed of 74 knots, which was below the recommended threshold specified in the Wipaire Inc. installation manual. Furthermore, the investigation identified that the AMPHIB PUMP 1 and 2 circuit breakers were found disarmed. It was determined that the pilot had a history of not utilizing checklists, a habit noted during a previous flight validation by ANAC. The investigation also noted that the engine and floats logbooks were unavailable for review.
Findings
- Failure to use checklists during pre-flight and flight phases prevented the pilot from identifying the incorrect aircraft configuration.
- Improper maintenance/configuration of the landing gear position warning system speed setting.
- Disarmed circuit breakers (AMPHIB PUMP 1 and 2) contributed to the inability to properly manage the landing gear system.
- Low situational awareness due to flight indiscipline and a lack of adherence to manufacturer-mandated procedures.
- Pilot attitude characterized by overconfidence, which led to the omission of critical flight phase checks.