What happened
On July 29, 1998, an Embraer E-110P1 Bandeirante, operated by Selva Táxi Aéreo with registration PT-LGN, departed Manaus for Tefé, Brazil. The aircraft was carrying 27 people, including 24 passengers and 3 crew members. During the initial climb, the crew noticed a drop in oil pressure in the left engine. Although the pilot continued the climb, the oil pressure eventually fell below the 40 PSI minimum limit, accompanied by an increase in interstage turbine temperature (ITT).
The crew followed procedures to shut down the left engine and attempted to return to Manaus. However, due to the aircraft being significantly overweight, the plane could not maintain level flight and began losing altitude. In an attempt to lighten the load, the crew jettisoned passenger luggage through an emergency exit. Despite this, the aircraft continued to descend, forcing a forced landing on the Manacapuru River. Upon impact with the water, the fuselage ruptured, causing the aircraft to sink rapidly.
The accident resulted in 12 fatalities, including 10 passengers and 2 crew members, along with 15 others suffering various injuries. One fatality was attributed to head trauma from a child sitting on an adult's lap, while others succumbed to drowning.
The investigation
CENIPA's investigation revealed a series of critical operational and maintenance failures. The aircraft was operating with an estimated excess weight of 852 kg above its maximum takeoff weight. This was due to an incorrect fuel load—the aircraft was filled to maximum capacity to avoid the higher cost of refueling in Tefé—and an inaccurate passenger manifest that failed to account for the true number of occupants and their weights.
Maintenance discrepancies were also central to the findings. The aircraft had exceeded its scheduled B2 inspection by 50 flight hours. Furthermore, the pre-flight A1 inspection was performed by an unqualified mechanic. The investigation also highlighted severe organizational pressures, noting that the pilots' salaries were overdue and were dependent on the revenue from this specific flight. The company owner had actively encouraged flying under these marginal safety conditions to maximize profit.
Findings
- Overweight Operation: The aircraft was approximately 852 kg over its maximum takeoff weight due to excessive fuel and passenger loading.
- Engine Failure: A drop in oil pressure in the left engine led to the emergency, likely caused by a leak or failure in the lubrication system.
- Maintenance Negligence: The aircraft was flying with an overdue B2 inspection and improper pre-flight checks performed by unauthorized personnel.
- Organizational Pressure: The operator incentivized unsafe operations, including flying with expired inspections and excessive weight, driven by financial motives.
- Inadequate Planning: Errors in the flight manifest, lack of a pre-flight briefing, and failure to verify weight and balance calculations contributed to the accident.
- Human Factors: The crew demonstrated poor judgment by continuing the climb after the initial signs of oil pressure loss and failed to properly verify the cargo manifest.