What happened
On March 22, 2003, an EMB 810C, registration PT-ETG, operated by Soure Táxi Aéreo Ltda, was performing a flight from Belém (SBJC) to the Ambrósio aerodrome (SIPY) in Portel, Pará. The aircraft was carrying a pilot and three passengers.
Upon arrival at the destination, the pilot observed that the unpaved runway, consisting of gravel and grass, was heavily saturated with standing water due to recent heavy rainfall. During the landing sequence, the pilot performed a touchdown that was described as long. As the pilot applied the brakes, the aircraft began to skid on the wet surface. In an attempt to stop the aircraft within the remaining runway limits, the pilot executed a sharp maneuver (a "ground loop"). However, the maneuver failed to arrest the aircraft's momentum, and the rear of the aircraft collided with a perimeter fence at the end of the runway. The aircraft sustained grave damage to the fuselage, horizontal stabilizer, elevator, and right flap, but all four occupants remained uninjured.
The investigation
CENIPA's investigation focused on the aircraft's configuration and the environmental conditions at the aerodrome. Investigators found that the aircraft's flaps were found in a position nearly fully retracted, which was inconsistent with the required configuration for the aircraft's weight and the short, wet runway. The investigation also noted that the aerodrome lacked a windsock, preventing the pilot from accurately assessing wind direction and intensity, which could have indicated a tailwind component.
Furthermore, the investigation examined the pilot's psychological state and the operator's oversight. It was noted that the pilot had been involved in a fatal accident seven months prior and was experiencing significant personal and financial stressors. Additionally, the investigation identified an organizational culture within the company that informally encouraged completing flights regardless of operational conditions.
Findings
- The pilot executed an unstable approach with an incorrect flap configuration and excessive speed.
- The runway surface lacked efficient drainage, leading to standing water and reduced braking effectiveness.
- The absence of a windsock at the aerodrome prevented the pilot from identifying potential tailwind components.
- The pilot's decision-making was likely compromised by high levels of anxiety and a lack of effective supervision from the aircraft operator.
- The aircraft's configuration (retracted flaps) was not compatible with the operational requirements of the short, wet runway.