What happened
On December 1, 2008, an Embraer EMB-810C, registration PT-RMP, operated by JVC Aero Táxi LTDA, was performing a transport flight from Manaus to Terra Santa, Brazil. The flight was intended to transport a patient on the return leg. Upon arriving in the vicinity of Terra Santa, the pilot failed to locate the authorized airstrip, which was situated 3.5km outside the urban area.
Instead, the pilot identified an old, decommissioned runway that had been out of service since 1999. By the time of the incident, this strip had been converted into the Evandro Pimentel Avenue, a public thoroughfare with active vehicle, pedestrian, and animal traffic. The pilot proceeded to land the aircraft on the avenue. During the landing roll, the aircraft passed in close proximity to a child on a bicycle; the resulting disturbance caused the child to fall, resulting in minor injuries.
The investigation
The investigation by SERIPA I revealed that the pilot relied on a private GPS for navigation and failed to cross-reference the coordinates with the ROTAER. This led to the input of coordinates pointing to the urban center rather than the official airstrip. The investigation also found that the pilot had been with the company for only three months and had not performed any route familiarization flights.
Furthermore, the investigation noted that the flight planning was rushed due to time constraints, as the pilot was attempting to complete the mission during daylight hours. The investigation also uncovered that the subsequent departure from the avenue the following day was conducted without authorization from the civil aviation authority. Additionally, the operator was found to be performing medical transport without the necessary certifications or specialized equipment.
Findings
- Inadequate flight planning and failure to verify navigational data against official aeronautical charts.
- Lack of route familiarization for a relatively new pilot.
- Reduced situational awareness caused by the pressure to complete the flight before sunset.
- Organizational failures regarding flight supervision and the authorization of unauthorized medical transport services.
- Use of an uncertified landing site consisting of an irregular surface with obstacles such as poles and wires.