What happened
On March 28, 1996, an Embraer 810 C, registration PT-EFR, was conducting a local check flight for multi-engine, commercial pilot, and instrument flight rules (IFR) qualifications in Barbacena, Minas Gerais. The flight involved a student pilot, an instructor, and a check pilot.
During the final approach to runway 18, the aircraft's approach speed was higher than prescribed, and the flare was performed at an excessive height. The student pilot failed to execute a go-around despite two instructions from the check pilot. As the aircraft attempted to land, it drifted left and collided with an embankment approximately 2/00 meters from the opposite runway threshold. The impact caused severe damage to the aircraft, including the engines, fuselage, and fuel systems, rendering the airframe a total loss. The instructor, seated in the rear, sustained serious injuries after loosening his seatbelt to monitor the situation, while the other two occupants were uninjured.
The investigation
CENIPA's investigation focused on the sequence of events leading to the loss of control. The investigation established that the flight was organized under significant time pressure, as the student's qualifications were set to expire that day. The check pilot had accepted the flight after being pressured by the instructor, despite having worked a long day.
Investigators examined the cockpit configuration and found that the check pilot was seated in the right seat, while the instructor was in the rear, which deviated from standard procedures for a student who was not yet qualified for solo operations. Furthermore, the investigation noted that the pre-flight briefing failed to detail emergency procedures for abnormal situations. During the landing attempt, the left engine reportedly failed. When the check pilot took control, he applied maximum power and pitched the nose up, which contradicted the aircraft's operating manual regarding engine failure procedures below 66 knots.
Findings
- Deficient Instruction: The student pilot's practical training was insufficient for the check flight, a fact the student himself acknowledged.
- Inadequate Crew Resource Management: The crew utilized cockpit resources improperly, with the instructor and check pilot in non-standard seating positions, and a failure to follow go-around instructions.
- Poor Decision Making: The decision to attempt a landing with an unstable approach was delayed, even though weather conditions allowed for a safe go-around.
- Inadequate Planning: The pre-flight briefing lacked specific instructions for handling abnormal engine failures.
- Improper Control Inputs: The check pilot's application of full power and nose-up attitude during an engine failure at low speed likely contributed to the loss of directional control.