What happened
On October 17, 2017, a Cessna 208 Amphibian, registration PR-MPE, was conducting a cargo and personnel transport flight from Manaus to the Anavilhanas Fluvial Archipelago in Brazil. During the approach to a water landing on the Rio Negro, the aircraft struck the river surface with its landing gear extended. The impact caused the aircraft to overturn and submerge.
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 a broken engine mount, damage to the propeller and engine, and the detachment of the float brackets, which led to the fuselage sinking.
The investigation
Investigators examined the aircraft's configuration and the pilot's operational procedures. It was discovered that the landing gear position warning system had been programmed to an airspeed of 74 knots, which deviated from the manufacturer's recommended range of 10 to 20 knots above the reference speed. Furthermore, the circuit breakers for the amphibian pumps were found in the disarmed position.
The investigation also reviewed the pilot's recent training history, noting that a previous flight validation had been marked unsatisfactory due to a failure to use required checklists. The investigation looked into the maintenance practices regarding the Wipaire Wipline 8000 floats and the procedures for rearming electrical components after emergency gear testing.
Findings
- The primary cause of the accident was the landing gear being in the extended position during the water landing.
- A lack of checklist discipline contributed to the pilot's failure to verify the aircraft's configuration and the status of the amphibian pump circuit breakers.
- The landing gear warning system was set to an incorrect airspeed, which prevented the pilot from receiving an audible alert that the gear was down for a water landing.
- Maintenance or pre-flight oversight left the amphibian pump circuit breakers disarmed, reducing the pilot's situational awareness regarding the aircraft's systems.
- The pilot's high level of experience may have led to an over-reliance on memory rather than following established procedures.