What happened
On January 5, 2011, an EMB-820C, registration PT-EHG, operated by Addey Táxi Aéreo Ltda., was performing a ferry flight from Salvador (SBSV) to the Fazenda Pontal Aerodrome (SDLO) in Cairu, Bahia. During the approach and landing phase, the pilot failed to command the extension of the landing gear. The aircraft subsequently performed a landing with the gear retracted, resulting in substantial damage to both engines, the flap panels, the fuselage underbelly, and both propeller assemblies. The pilot was uninjured.
The investigation
CENIPA's investigation established that the pilot, a highly experienced aviator with over 27,000 flight hours, did not utilize the aircraft checklist during the approach and landing phase. While the pilot reported that a landing gear warning alarm failed to sound, post-accident testing of the aircraft's warning system showed no malfunctions.
The investigation also examined the pilot's operational workload. On the day of the accident, the pilot had already completed seven takeoffs and landings, part of a heavy flight schedule typical of the high tourist season. The investigation noted that the repetitive nature of short-duration flights can negatively impact cognitive functions related to information retrieval, potentially leading to the omission of critical procedures.
Findings
- Failure to use checklists: The pilot did not follow standard operating procedures by omitting the use of the checklist during the approach.
- Potential fatigue: The pilot's workload during the high season was significant, and the pilot described the recent flight routine as exhausting, which may have impaired cognitive performance.
- Operational routine: The high frequency of short-duration flights (up to eight takeoffs per day) may have contributed to a loss of situational awareness or procedural oversight.
- Lack of managerial oversight: There was an absence of adequate management supervision to monitor operational performance and identify potential risks related to crew fatigue or stress.