What happened
On December 24, 1994, an EMB-720 aircraft, registration PT-EVZ, departed from Redenção, Pará, bound for an unregistered landing strip at the Santilho mining site. While approximately 40 km from the intended destination, the aircraft experienced an engine failure. The pilot attempted an emergency landing in a nearby river, causing the aircraft to submerge. The impact resulted in three fatalities (one crew member and two passengers) and left two other passengers with injuries, ranging from serious to light. The aircraft was subsequently considered a total loss.
The investigation
CENIPA's investigation faced significant challenges due to the irregular nature of the operation and limited access to the crash site in the jungle. Investigators found that the pilot was operating with an expired technical qualification certificate (CHT). Furthermore, while the aircraft's airworthiness certificate was valid, maintenance was being performed at the mining site by unqualified personnel. The investigation also noted that the destination landing strip was clandestine and not officially registered or approved. Due to the loss of aircraft logs and the unavailability of certain witnesses, a definitive cause-and-effect relationship could not be established with absolute certainty, though strong evidence pointed toward systemic maintenance failures.
Findings
- Inadequate maintenance: Maintenance tasks were being performed by unauthorized individuals at the mining site, likely leading to the engine failure.
- Flight indiscipline: The pilot was operating with an expired technical qualification and was flying to an unregistered, clandestine airstrip.
- Deficient supervision: The aircraft owner permitted the use of an uncertified pilot, allowed unauthorized maintenance practices, and sanctioned operations at an unapproved landing strip.