What happened
On May 7, 1994, an EMB 110E, registration PT-GJW, operated by Rico Táxi Aéreo Ltda, was performing a flight from Santa Isabel do Rio Negro to São Gabriel da Cachoeira, Amazonas. At the time of the intended arrival, the destination aerodrome was closed for IFR (Instrument Flight Rules) operations due to adverse meteorological conditions, characterized by rain and heavy cloud cover with bases below minimum requirements.
During the approach, the aircraft flew an oblique trajectory relative to the runway and collided with the ground approximately 150 meters from the runway threshold. While the impact occurred in a controlled attitude to avoid a stall, the aircraft sustained damage beyond repair. There were 12 injuries among the passengers, and the pilot sustained 1 injury.
The investigation
The CENIPA investigation established that the crew attempted to proceed with the approach despite the lack of visibility and the airport's closed status. The investigation highlighted a significant lack of flight safety doctrine and operational supervision within the operator's organization.
Investigators found that the crew failed to follow standard instrument approach procedures and did not perform a proper briefing for the descent. Furthermore, the investigation noted a lack of Crew Resource Management (CRM), as the co-pilot's lack of experience and tendency toward passivity prevented effective monitoring of the flight parameters. The investigation also noted that the pilot in command exhibited an aggressive approach to the flight, attempting to improvise procedures to force a landing despite the weather.
Findings
- Improper flight discipline: The pilot continued the flight at an altitude below the minimum required for the prevailing weather conditions.
- Loss of situational awareness: The pilots became excessively focused on searching for ground references, which distracted them from maintaining basic flight parameters.
- Operational deficiencies: The operator lacked effective oversight, systematic flight safety training, and a formal simulator training program for the EMB 110E.
- Inadequate Crew Resource Management (CRM): There was a failure in cockpit coordination, specifically regarding the lack of a descent briefing and the failure of the co-pilot to monitor the flight after the critical point of the approach.
- Environmental factors: Low visibility and the inherent imprecision of the NDB (Non-Directional Beacon) contributed to deviations during the descent.