What happened
On April 3, 2009, an EMB-721C, registration PT-RNL, was performing an aeromedical transport mission from Catolé do Rocha, PB, to João Pessoa, PB. The flight, operated by Piquiatuba Táxi-Aéreo Ltda., carried a pilot, a patient, a doctor, a nurse, and one passenger.
Following a difficult departure from the previous stop, the aircraft experienced a total electrical failure approximately 20 minutes into the flight. This failure resulted in the loss of several systems, including radio communications. Due to the lack of communication, the pilot had to coordinate with the João Pessoa Tower via mobile phone.
Before landing, the pilot performed low approaches to verify the landing gear position, as the landing gear indicator lights were inoperative. After receiving information from the tower that the gear appeared down and locked, the pilot proceeded with the landing. However, upon touchdown, the nose gear retracted, causing damage to the propeller, the engine, and the lower section of the aircraft's nose. The pilot and all passengers were uninjured.
The investigation
CENIPA's investigation established that the aircraft had a history of intermittent electrical failures that were not being recorded in the aircraft logbook. The investigation also noted that the pilot had landed at an airfield that was officially closed via NOTAM. Furthermore, the investigation examined the operational decision-making regarding the use of a single-engine aircraft for a long-range aeromedical mission under such degraded technical conditions.
Findings
- Inadequate flight planning, which led to the necessity of landing at a closed airfield.
- Management oversight, as the operator allowed the use of an aircraft with a known history of electrical issues for a complex, long-distance medical transport mission.
- Failure to maintain accurate records, specifically the lack of formal entries in the aircraft logbook regarding previous electrical malfunctions.
- Risk underestimation by the pilot regarding the impact of multiple engine start attempts on the aircraft's battery capacity.
Safety action
CENIPA issued several recommendations, including:
- To the operator: Implement mechanisms for the reliable recording of aircraft malfunctions in logbooks and improve risk management for complex operations.
- To INFRAERO: Improve maintenance and operational control of visual signaling equipment (light guns) at control towers.
- To DECEA: Evaluate the installation of dedicated emergency telephone lines at control towers for aircraft in distress.