What happened
On the night of November 15, 1997, a Beech 95-A-55, registration PT-BXD, operated by Tapajós Táxi Aéreo, crashed in a dense jungle region near Trombetas, Pará. The aircraft had departed from Trombetas for Santarém to transport two passengers, including a sick child. After takeoff from runway 27, the aircraft failed to establish contact with radio communications.
Following an eight-day search by the Brazilian Air Force, the wreckage was located approximately 3 km from the Trombetas aerodrome. The impact occurred in a heavily forested area, with the aircraft striking the ground at a 10-degree angle. The crash resulted in three fatalities: the pilot and both passengers. The aircraft was destroyed by fire following the impact.
The investigation
CENIPA's investigation focused on the mechanical state of the aircraft and the operational environment. Investigators found that the aircraft's maintenance records were inadequate, making it impossible to verify the periodicity of essential services. Notably, the altimeter had not been calibrated within the previous 24 months, and the aircraft's weight and balance records were expired. Furthermore, the aircraft lacked dual flight controls, which was required for the type of operation performed.
Analysis of the wreckage revealed that the number 2 engine was producing no power at the time of impact, as evidenced by the fractured propeller shaft and reduced fuel and power levers. The investigation also noted that the pilot was operating as a "freelance" pilot without a formal employment contract, which prevented the implementation of a standardized training program.
Findings
- Engine Failure or Spatial Disorientation: The investigation considered two primary hypotheses. The first was a failure of the number 2 engine, potentially linked to improper maintenance. The second was spatial disorientation, exacerbated by the pilot's known visual difficulties, the lack of a co-pilot for IFR operations, and a potentially erroneous altimeter reading.
- Operational Non-compliance: The flight was conducted under IFR conditions at night with only a single pilot, violating regulations that require a second pilot for such operations.
- Management Failures: The operator lacked proper oversight, delegating all flight responsibilities to the pilot and failing to ensure a standardized training program or proper pilot employment contracts.
- Pilot Performance: The pilot was noted for non-standardized cockpit procedures, a lack of attention to safety, and a habit of maintaining low altitudes during takeoff, which increased the risk of collision with the high vegetation near the runway.