Accident Overview
An aircraft conducting a flight from Tefé to Manaus was on an instrument landing system (ILS) approach to Runway at Manaus-Eduardo Gomes Airport. The flight had been uneventful until air traffic control (ATC) instructed the crew to execute a go-around and follow a holding pattern because priority had been given to an ambulance flight. The crew initiated the go-around by making a left turn to a heading of 060 degrees.
While executing the go-around, the crew descended through 2,000 feet and continued descending until the aircraft struck the ground. The impact occurred approximately 33 kilometers from the airport. The aircraft disintegrated on impact, and all 33 occupants on board were killed.
Flight History
The aircraft had been correctly established on the ILS when the go-around instruction was received. The crew acknowledged the instruction and began the missed approach procedure. Instead of climbing, the aircraft continued to descend after passing 2,000 feet. The descent was not arrested, and the aircraft ultimately collided with terrain.
Probable Cause
According to the official investigation, the probable cause of the accident was controlled flight into terrain after the crew continued the descent below 2,000 feet until the aircraft impacted the ground. The following contributing factors were identified:
- The crew reported their altitude at 2,000 feet while the actual altitude of the airplane was 1,300 feet.
- The crew continued the descent until final impact.
- The crew did not react to the Ground Proximity Warning System (GPWS) alarm, which sounded four times when the aircraft reached an altitude of 400 feet.
- No corrective action was taken by the crew.
- Lack of crew coordination.
- Poor approach planning that led the aircraft to descend to a critical altitude.
- Lack of supervision.
- Operational deficiencies.
Conclusion
The investigation concluded that the crew's failure to maintain altitude awareness and respond to alerts led to the accident. The aircraft was fully capable and under control until impact, but the crew's actions resulted in a controlled flight into terrain.