What happened
On March 30, 1999, an EmbraER EMB-110 P1, registered as PT-LNW, was operating a chartered flight from Manaus to Coari, Brazil, carrying two crew members and 13 passengers. During the flight, the crew observed an engine fire warning light on the left engine. Due to unfavorable weather conditions at the intended destination, the crew decided to divert to an uncertified landing strip in Tapauá, Amazonas.
After landing in Tapauá, the crew performed ground checks, which resulted in the fire warning light turning off. Believing the issue was resolved, the pilots decided to proceed with a takeoff to continue to Coari. During the takeoff roll, the pilot attempted to maneuver the aircraft to avoid potholes on the irregular asphalt surface. This maneuver caused the left main gear to leave the runway. After traveling approximately 280 meters with the gear off the pavement, the pilot attempted to abort the takeoff, but lost control of the aircraft, causing it to collide with an embankment on the left side of the runway. The aircraft sustained heavy damage to the landing gear, left wing, fuselage, propeller, and engine, but all 15 occupants escaped without injury.
The investigation
CENIPA's investigation focused on the decision-making process and the operational environment of the uncertified airfield. Investigators examined the runway conditions at Tapauá, which was noted as being uncertified, unrecorded, and lacking any airport infrastructure, characterized by a narrow, smooth, and potholed asphalt surface. The investigation also reviewed the maintenance records of the EMB-110 P1, finding them to be adequate and up to date.
Investigators analyzed the crew's actions regarding the engine fire warning and their failure to notify air traffic control of their diversion or intentions. Furthermore, the investigation scrutinized the organizational culture of the operator, Meta Táxi Aéreo, regarding its oversight of flight safety and its practice of authorizing operations at uncertified strips.
Findings
- Improper Risk Assessment: The crew failed to properly evaluate the risks of taking off from an irregular, uncertified runway, overestimating their experience.
- Inadequate Emergency Management: The decision to proceed with takeoff based solely on the extinguishing of the fire warning light, without following full manufacturer-prescribed procedures, was a critical error.
- Poor Runway Management: The pilot's attempt to avoid potholes led to a lateral deviation that exceeded the aircraft's physical capabilities on the narrow 10-meter wide runway, resulting in the loss of directional control.
- Organizational Safety Deficiencies: The operator demonstrated a lack of flight safety supervision by allowing the use of uncertified strips and failing to provide guidance to the crew regarding the risks involved.
- Lack of Communication: The crew failed to perform a takeoff briefing and did not inform regional air traffic control of their landing or subsequent takeoff intentions.