Accident Overview
The aircraft departed São Paulo-Congonhas Airport at 1630 local time on a flight to Belém, carrying two passengers and two pilots. During the approach to Belém-Val de Cans-Júlio Cezar Ribeiro Airport runway 06 by night, one engine flamed out. Seconds later, the second engine failed. The crew ditched the aircraft in the Bay of Guajará, approximately 1.2 km short of the runway 06 threshold. All four occupants were rescued by servicemen of the Naval Base who were on duty at the time. A pilot was slightly injured, while the other three occupants escaped uninjured. The aircraft sank and the wreckage was recovered 12 days later.
Flight Planning and Fuel Management
The flight plan from SBSP to SBBE indicated a fuel endurance of 7 hours 30 minutes for an estimated elapsed time of 5 hours 40 minutes at FL230. When passing over Palmas, the pilots decided jointly to proceed non-stop to the destination, discarding an intermediate refueling stop. The fuel quantity indicators and fuel flow indicators were not showing dependable information. The flight plan contained information about sick person transportation, but no sick person was on board. The aircraft was registered in passenger transport category (TPP) and was engaged in transport of a sick person.
Crew and Aircraft Information
Both pilots held valid aeronautical medical certificates and technical qualification certificates. The captain had qualification and sufficient experience for the flight; the copilot was under training. The aircraft had a valid airworthiness certificate. The captain planned the flight considering full fuel load.
Investigation Findings
The official investigation identified findings including that the pilots had valid certificates, the aircraft was airworthy, and the captain had experience. The crew decided to fly non-stop despite instrument malfunctions. The aircraft ditched 1,200 meters short of the runway threshold. One pilot and both passengers were uninjured; the other pilot suffered minor injuries. The aircraft sustained substantial damage.
Contributing factors included: the captain's failure to comply with norms by flying on his day of rest and overconfidence in fuel endurance; the copilot's lack of assertiveness; inappropriate decision-making; flight indiscipline (violating regulations); a probable deviation in training regarding emergency exit procedures; inappropriate piloting judgment; and flight planning errors. Organizational factors included delegation of planning to the crew and a company culture allowing operations beyond certification.