What happened
On September 15, 1998, an EMB-710C, registration PT-NSK, was performing a flight between two unauthorized, clandestine airstrips in Brazil. The flight originated from Lagoa Verde, Maranhão, with the destination of Dom Elizeu, Pará. During the flight, the pilot noticed fluctuations in the fuel pressure gauge and decided to perform a precautionary landing on the BR-010 highway near Itinga, Maranhão.
After landing on the roadway, the pilot inspected the engine and determined the pressure fluctuation was likely just an indication error. The pilot then requested that local residents temporarily block a 350-meter section of the highway to allow for a takeoff. During the takeoff roll, the aircraft struck an unmarked speed bump (redutor de velocidade). The impact caused the aircraft to veer left, leading to a collision with a parked truck and subsequently a pickup truck. The aircraft sustained severe damage to its structure, wings, propellers, and engine, while the pilot sustained minor injuries.
The investigation
CENIPA's investigation revealed several significant regulatory and safety violations. The aircraft was operating with an expired Certificate of Airworthiness, an expired annual maintenance inspection, and expired mandatory insurance. Furthermore, the flight was conducted without a flight plan and utilized unauthorized airstrips.
Investigators found evidence that the pilot may have been using a GPS as his primary navigation source rather than aeronautical charts, as he was unable to determine his exact position when the GPS failed. The investigation also noted that the aircraft lacked seatbelts/restraints, which was a violation of the technical manual and contributed to the pilot striking the instrument panel during the impact. The pilot's decision-making was also influenced by psychological pressure, as he feared retaliation from local residents following his low-altitude flyovers used to signal the road closure.
Findings
- Improper takeoff site: The decision to take off from a highway and the failure to verify obstacles like the speed bump were primary factors.
- Inadequate maintenance: The aircraft had expired inspections and lacked required seat restraints.
- Operational non-compliance: The flight involved the use of clandestine airstrips and a lack of flight planning.
- Navigation errors: Potential over-reliance on GPS as a primary navigation tool in VFR conditions.
- Human factors: The pilot exhibited signs of complacency, insecurity, and psychological pressure, which compromised his professional judgment.