What happened
On September 25, 2003, an NE-821 operated by EMSA (Empresa Sul Americana de Montagems S.A.) departed from Goiânia (SBGO) for a flight originally filed for Jussara, GO. However, the flight proceeded to an unregistered landing strip at Fazenda do Encantado in Baliza, GO, approximately 86 NM away from the filed destination.
Upon arrival, the pilot performed a low pass over the farm at the request of a passenger before attempting a landing. The approach was unstabilized, characterized by a short, left-hand pattern. The aircraft touched down with the left landing gear first, while the aircraft was still banked to the left and misaligned with the runway centerline. As the right landing gear contacted soft sand outside the runway limits, the pilot lost directional control. The aircraft veered across the runway, causing the left landing gear to collapse in a sandy ditch. The resulting excursion led to a collision with a tree, which severed the left wing and engine, triggering a massive fire that consumed the aircraft.
Of the five occupants on board, the pilot and two passengers sustained severe burns. Tragically, two passengers died—one 17 hours after the accident and another four days later.
The investigation
CENIPA's investigation established that the aircraft had departed with an excess weight of approximately 93 kg above the maximum takeoff weight. At the time of landing, the aircraft was likely at or slightly above its maximum landing weight. The investigation also noted that the pilot had intentionally bypassed regulations by filing a flight plan for a different destination to avoid scrutiny regarding the use of the unregistered strip.
Investigators examined the operational environment, noting that the pilot was a "free-lance" contractor without a formal training or proficiency monitoring program from the operator. The lack of infrastructure at the landing site meant there were no firefighting services available to assist during the post-crash fire.
Findings
- Unstabilized approach: The pilot attempted to land following an improper, short-pattern approach that lacked proper alignment and stabilized parameters.
- Operational non-compliance: The pilot and operator demonstrated complacency by planning and executing a flight to an unauthorized, unregistered landing strip.
- Weight and balance: The aircraft departed significantly above the maximum takeoff weight and landed at or above maximum landing weight.
- Lack of oversight: The operator failed to implement a system for monitoring pilot proficiency or providing recurrent training, particularly for contract pilots.
- Pilot judgment: The pilot made poor decisions regarding the use of engine power and control inputs to correct the aircraft's path after the initial touchdown.
Safety action
CENIPA issued several recommendations, including:
- Instructions for executive aviation companies to emphasize the importance of emergency briefings for passengers.
- A requirement for operators to establish formal systems for assessing pilot performance and technical proficiency.
- The implementation of recurrent training programs for pilots, specifically focusing on aircraft performance, maximum takeoff/landing weights, and emergency procedures.