What happened
On January 22, 1976, at 15:40 local time, an Embraer EMB-890 Bandeirante, registration PP-TBD, was performing a takeoff from the Chapecó airport in Santa Catarina, Brazil. During the takeoff roll, the right tire burst. The crew was unable to stop the aircraft within the available runway area, causing it to overshoot the pavement. The aircraft careened into a steep embankment, which significantly worsened the impact and triggered a fire. The accident resulted in seven fatalities (the pilots and six passengers) and one passenger sustained serious injuries. The aircraft was a total loss.
The investigation
The CENIPA investigation examined several factors, including human performance, aircraft maintenance, and airport infrastructure. While the pilots' medical certificates were valid and no physiological or psychological impairments were found, the investigation identified significant operational and infrastructural issues.
Regarding the aircraft, investigators noted that while no mechanical system failures were confirmed, there were documented maintenance deficiencies in the landing gear systems during the preceding months. The investigation also noted that the aircraft was carrying 980 kg of fuel, which, while within limits, could have been reduced to 660 kg to improve takeoff performance on the challenging runway.
Findings
- Infrastructure Deficiencies: The runway at Chapecó was in poor condition, consisting of gravel with large, sharp stones that likely caused the right tire to burst. Furthermore, the usable runway width was only 10 meters due to overgrown grass, and the lack of paved shoulders led the aircraft into a 16-meter deep depression at the runway end.
- Operational Deficiencies: The crew did not utilize all available performance resources. There were indications that the pilots did not use maximum takeoff torque or full reverse thrust. The use of full reverse thrust was reportedly avoided during normal operations to prevent passenger discomfort, leading to a lack of familiarity with the technique during the emergency.
- Emergency Procedures: The investigation found that the pilot did not utilize the emergency landing gear retraction system, which might have helped the aircraft stop before hitting the embankment. Additionally, the investigation noted that the aircraft's flight manual lacked sufficient clarity regarding emergency procedures for ground operations involving tire bursts.
- Maintenance and Support: There were indications of inadequate maintenance practices regarding the landing gear and a lack of investigation into the relationship between previous landing gear failures and the accident.