What happened
On January 11, 2001, at approximately 14:40 local time, a BN 2 A 21 Islander, registration PT-KNE, crashed near the summit of Serra Preta in Érico Cardoso, Bahia. The aircraft, operated by LASA Engenharia e Prospecções S/A, was conducting an aerogeophysical mineral prospecting mission departing from Paramirim.
The crew, consisting of a commander, a co-pilot undergoing type adaptation, and a prospecting technician, was flying in an area characterized by significant cloud cover and unstable weather due to a passing cold front. The aircraft was fully fueled with a seven-hour endurance for a mission estimated to last only three hours. During the flight, the aircraft struck the terrain near the mountain peak, approximately 200 feet from the summit. The impact was followed by a massive post-crash fire that completely consumed the aircraft and all three fatalities on board.
The investigation
CENIPA investigators established that the aircraft struck the ground in a stalled condition, with both engines still producing power at the moment of impact. Evidence from the propellers and engine exhausts indicated high temperatures and operational power during the collision.
The investigation examined the meteorological conditions, noting a high probability of windshear due to the local topography and the presence of a cold front. Investigators also reviewed the operational practices of the operator, finding that the crew relied on empirical, non-standardized methods to assess weather visibility—such as observing a mountain from their hotel—rather than utilizing formal meteorological reports. Furthermore, the investigation looked into the company's oversight, noting that the flight took place outside the recommended area for the co-pilot's adaptation and during a time of day (afternoon) when turbulence is typically higher than the recommended morning period.
Findings
- Adverse meteorological conditions, including the high probability of windshear and low visibility, contributed to the accident.
- Deficient judgment by the crew regarding the decision to fly in unstable weather and the choice of flight path.
- Deficient planning, specifically the unnecessary increase in aircraft weight caused by carrying seven hours of fuel for a three-hour mission.
- Inadequate supervision by the operator, which allowed non-standardized procedures (such as using flaps to clear obstacles) and failed to monitor recent flight incidents involving the pilot.
- Operational fatigue and physical exhaustion, as the nature of low-altitude prospecting flights is extremely demanding, compounded by inadequate crew accommodations.