Accident Details
Shortly after takeoff from The Pikany Indian Reserve Airfield, during initial climb, a twin-engine aircraft lost height, struck trees, and crashed in a wooded area approximately one kilometer from the airstrip. The aircraft was destroyed. All five occupants were killed, among them members of the Kayapo indigenous group who were flying to Novo Progresso to receive urgent medical care.
Investigation Findings
The official investigation identified several factors that contributed to the accident. The operation involved an aircraft not listed in the company's Operating Specifications, and the runway used was neither registered nor approved. The pilot lacked the required flight hours and specific training for the aircraft type. Investigators noted a possible failure to verify the fuel quantity before takeoff. The pilot and a coordinator, who may have acted as an instructor, lacked necessary training, which could have compromised their performance during flight preparation and execution. There were indications that the pilot may have failed to comply with minimum fuel requirements. Additionally, the pilot's qualifications had expired, and it was not determined whether the coordinator was at the controls at the time of the accident. The transport of a cylinder onboard the aircraft violated regulations prohibiting such material. The lack of training on aircraft differences may have contributed to the failure to check fuel tanks, a procedure prescribed in the manual. Inexperience in single-engine operations may have been a factor. The emergency nature of the flight—providing urgent care—may have led the pilot to overlook safety parameters. The pilot's desire for operational promotion may have incentivized disregarding minimum safety requirements. The company's management lacked control over flights outside the main base, allowing the pilot and base manager to operate without authorization. Contracting organizations failed to supervise the air transport service, exposing passengers to risks of irregular operations.
Probable Cause
The official probable cause identified multiple factors: utilization of an unauthorized aircraft and unapproved runway; pilot lacking hours and specific training; possible failure to verify fuel; inadequate training for pilot and coordinator; possible noncompliance with fuel regulations; expired pilot qualifications; unauthorized transport of a cylinder; lack of training on aircraft differences; emergency context potentially causing oversight; pilot's motivation for promotion; possible loss of control after engine failure due to inexperience; lack of company management control; and lack of supervision by contracting organizations.