What happened
On May 11, 1998, an EMB-810C operated by Sete Táxi Aéreo Ltda. was performing a flight from São Luís to Brejo, with a planned stop in Tutóia, Maranhão, to deliver bank mail. Upon arriving at the Tutóia aerodrome, the pilot performed three low passes over the runway to clear the area of pedestrians and animals, as the strip lacked perimeter fencing.
Following the third pass, the pilot proceeded with the landing. During the landing roll, a pedestrian entered the runway directly in front of the aircraft. The right wing of the aircraft struck the individual, resulting in one fatality. The aircraft sustained minor damage to the right wing fuel tank area, and the pilot remained uninjured.
The investigation
CENIPA's investigation focused on the operational conditions of the Tutóia aerodrome and the organizational practices of the operator. The investigation established that the aerodrome was an unauthorized, clandestine strip that had not been registered or regulated since 1990. The facility lacked air traffic control, had no lateral markings, and featured uneven terrain and encroaching vegetation.
Investigators found that the operator, Sete Táxi Aéreo Ltda., had been regularly using this uncertified strip for daily mail deliveries. The investigation also examined the pilot's decision-making process, noting that while the pilot attempted to clear the runway via low passes, the lack of a certified infrastructure made a safe landing impossible once the pedestrian entered the path.
Findings
- Lack of oversight: The operator lacked adequate supervision to prevent regular operations at uncertified and unsafe landing sites.
- Flight indiscipline: The pilot operated at an uncertified aerodrome in violation of existing aviation regulations.
- Inadequate infrastructure: The narrow runway, lack of lateral markings, and uneven terrain prevented the pilot from performing an evasive maneuver or a go-around once the pedestrian appeared.
- Organizational culture: A culture of non-compliance existed within the company, characterized by improvised procedures and the routine use of unauthorized landing strips.