Accident Overview
On an unspecified date, a single-engine aircraft departed Manaus-Eduardo Gomes Airport at 1220 local time on a flight to the Anavilhanas Archipelago. The aircraft carried cargo, four passengers, and one pilot. Upon landing on the Rio Negro, the airplane struck the water surface and crashed upside down before coming to rest partially submerged. The pilot and three passengers were rescued, while a fourth passenger was killed.
Probable Cause and Contributing Factors
The official investigation determined the probable cause of the accident: the aircraft landed on the water with the landing gear in the down position. The investigation also identified several contributing factors:
- Attitude: The pilot failed to comply with the checklist during pre-flight inspection and the flight itself, favoring a landing with inadequate configuration. This attitude may have been influenced by the pilot's confidence in his operational capability due to his long experience in aviation.
- Flight Indiscipline: Non-compliance with the checklist indicated a low level of situational awareness and a low concern for safe flight conduct by failing to follow basic procedures from the manufacturer's manuals and regulations.
- Piloting Judgment: The pilot's choice not to use the checklist during flight phases revealed inadequate evaluation of parameters related to aircraft operation. Improper compliance with the Pre-Flight Inspection Sheet prevented the AMPHIB PUMP 1 and 2 circuit breakers from being rearmed.
- Aircraft Maintenance: After testing landing gear extension and retraction via the emergency system, the AMPHIB PUMP 1 and 2 circuit breakers were not rearmed, and the aircraft was delivered to fly in this condition. The AIRSPEED switch setting of the landing gear position warning system computer was set to 74 kt, which was not in accordance with the recommended speed in the Wipaire Inc. 9600-1A installation manual, revision G.
- Memory: The AMPHIB PUMP 1 and 2 circuit breakers were found disarmed after the occurrence, indicating that after maintenance, the person performing the tasks likely forgot to reconfigure the aircraft. Additionally, the pilot's automatism in air operations without using a checklist may have prevented correct perception of the circuit breaker condition and erroneous landing gear positioning.
- Perception: The landing on water with the aircraft in an inadequate configuration for the situation denotes a decrease in the pilot's situational awareness, as necessary factors and conditions for safe operation were not observed.