What happened
On August 22, 2007, at approximately 03:35 UTC, an EMB-110P1, registration PT-SDB, operated by TWO Táxi Aéreo Ltda., crashed near the Guatupê Military Police Academy in São José dos Pinhais, Paraná. The aircraft had departed from Curitiba (SBCT) for a repositioning flight to Jundiaxi (SBJD). Approximately two minutes after takeoff, the aircraft entered a dive and struck the ground. The impact destroyed the aircraft, and both pilots sustained fatal injuries.
The investigation
CENIPA's investigation focused on the flight sequence, the aircraft's technical condition, and the operational environment. Investigators found that the aircraft was equipped with a temporary, non-standard attitude indicator (horizon) located below the primary position due to a recent failure of the main unit. The investigation also examined the crew's flight experience, the company's management practices, and the meteorological conditions, which featured low ceilings and restricted visibility.
Findings revealed significant regulatory and organizational deviations. The pilot in command had exceeded legal duty limits and had not received the required rest period. Furthermore, the crew had intentionally bypassed standard operating procedures, including the use of checklists and the filing of a flight plan under a different pilot's name. The investigation also noted that the company's management style placed high pressure on crews to complete missions regardless of safety risks, often with inadequate supervision and planning.
Findings
- Loss of control in flight caused by spatial disorientation, potentially exacerbated by the pilot's failure to properly utilize or even activate the substitute attitude indicator.
- Organizational failures, including inadequate management planning, lack of proper supervision, and a high-pressure work environment that prioritized financial results over safety.
- Violation of operational regulations, specifically regarding flight duty period limits, mandatory rest periods, and the intentional omission of checklist usage.
- Inadequate maintenance oversight, as engine and propeller logbooks were found to be out of date.