What happened
On June 1, 1999, at 05:09Q, an EMB-810 D, registration PT-VAR, operated by Mato Grosso do Sul Táxi Aéreo, was involved in a collision with an obstacle near Chapadão do Sul, MS. The flight departed from Campo Grande at 03:46Q with a flight plan filed for Jataí, GO. However, the actual intended destination was an uncertified dirt landing strip at Fazenda Estiva.
During the descent, the pilot reported experiencing engine vibrations and power loss in the right engine, prompting the decision to divert to the farm strip. While performing the night approach, the aircraft's right wing struck an electrical pole approximately 6 meters high. The impact tore the right wing and engine from the airframe, causing severe damage to the cockpit and left wing. The pilot sustained severe injuries, specifically a fractured leg, and the aircraft was a total loss.
The investigation
CENIPA's investigation revealed that the flight was being conducted under highly irregular conditions. Although the flight plan indicated a destination with night lighting capabilities (Jataí), the pilot was actually navigating to an uncertified strip with no lighting infrastructure. The investigation found that the aircraft was configured to transport two funerary urns, confirming the mission to the farm.
Investigators noted that the pilot failed to account for the fact that the arrival would occur in total darkness. While witnesses suggested that cars were intended to provide makeshift lighting for the strip, this was not in place at the time of the accident. The investigation also highlighted significant organizational pressures, noting that the operator's commitment to fulfilling the contract likely influenced the decision to fly under unsafe, marginal conditions.
Findings
- Improper Flight Planning: The pilot filed a flight plan with a false destination and failed to plan for a nighttime arrival at an unlit, uncertified field.
- Operational Deviations: The operator authorized a flight to a location lacking the necessary infrastructure for night operations.
- Loss of Situational Awareness: Due to the lack of ambient light and the absence of runway lighting, the pilot suffered from impaired depth perception, leading to an incorrect assessment of altitude during the approach.
- Organizational Pressure: Latent failures within the operator included a culture of prioritizing mission completion over safety standards, often referred to as "marginal-technical behavior."