What happened
On September 30, 2001, an Embraer 810D operated by Taguá Agropecuária Ltda. crashed into the Serra do Facão mountains near Cáceres, Mato Grosso. The flight departed from Várzea Grande (SBCY) with the intention of transporting a state official to a local ceremony.
As the aircraft approached its destination, the pilot contacted a nearby police helicopter, Águia Uno, to receive updated weather information. The pilot was informed that while the airfield was experiencing mist, conditions were expected to improve. Approximately four minutes before the scheduled landing, the aircraft struck terrain at an altitude of roughly 1,600 feet. The impact resulted in two fatalities and the total destruction of the aircraft.
The investigation
CENIPA's investigation focused on the pilot's decision-making and the operational environment. The investigation established that the aircraft was in good mechanical condition, with all maintenance records up to date and the center of gravity within limits. The pilot was highly experienced in the region and held valid licenses and medical certificates.
Investigators examined the meteorological conditions, noting that while visibility was greater than 10 km, a layer of stratus cumulus and heavy mist obscured the Serra do Facão. The investigation also looked into the pilot's flight plan, which was filed as a visual flight rules (VFR) flight, despite the aircraft entering instrument meteorological conditions (IMC) during the descent.
Findings
- Loss of situational awareness due to psychological pressures, including the urgency to meet a strict schedule for the passenger and the high-profile nature of the flight.
- Improper descent profile, as the pilot descended below the minimum safe altitude for the sector while flying in IMC.
- Operational deficiencies, specifically the use of a "free-lancer" pilot model, which prevented the operator from effectively communicating safety culture and oversight.
- Flight rule non-compliance, as the pilot continued the descent into instrument conditions despite having filed a VFR flight plan.
- Inadequate planning, as the pilot failed to maintain a safety margin relative to the terrain elevations while attempting to penetrate the cloud layer.