Accident Details
A twin-engine aircraft operated an on-demand flight from Dourados-Francisco de Matos Pereira Airport to Curitiba-Bacacheri Airport. The aircraft carried two pilots, two passengers, and a load of valuables. During the final approach to Curitiba-Bacacheri Airport, both engines failed simultaneously. The crew attempted an emergency landing, but the aircraft crashed in a field and came to rest near trees.
Casualties
Three occupants were killed in the crash. One passenger was seriously injured and became the sole survivor but died the following day from injuries sustained in the accident. All four occupants ultimately lost their lives.
Probable Cause Findings
Official findings identified multiple factors. Fatigue likely occurred due to high workload, affecting crew perception and judgment. The captain displayed an attitude of gratitude toward the hiring company, working consecutive hours beyond prescribed limits, which may have impaired his evaluation of safe flight conditions. The crew did not gather or properly evaluate available information for correct refueling, leading to a decision not to refuel at one location. Company crews typically did not keep fuel records, relying on approximate calculations from previous flights with unreliable control parameters, reflecting a work-group culture that became apparent in this accident.
Pilots presumably experienced stress from daily flying with little rest or holidays, which may have weakened performance. Security concerns regarding the transport of valuables likely affected decisions, such as not refueling at certain locations. The company's work structure caused routine overload with many flights and few breaks, interfering with crew performance. The company did not monitor pilot performance to identify deviations from standard procedures. Failures in applying operational norms and communication between crew members may have occurred due to inadequate task management, including checklist use and fuel consumption control forms.
The crew judged the aircraft's fuel quantity sufficient, but fuel gauges did not indicate the correct amount, directly influencing flight outcome by affecting planning and situational awareness. The crew did not appropriately analyze fuel needs for the flight leg between two airports. The Mission Order did not establish a minimum fuel quantity, leaving the decision to the captain. The company lacked rigor in completing aircraft logbooks and cargo manifests, leading to no control over operational procedures, which may have resulted in the aircraft taking off with insufficient fuel. Although the company's Manual of General Operations had parameters for calculating endurance, it did not define fuel in Mission Orders, transferring responsibility to the captain.