What happened
On August 28, 1998, an Embraer E-110 P1, registration PT-OCW, operated by TAVAJ–Transportes Aéreos Regionais S/A, was performing a regional flight from Parintins to Manaus, with a scheduled stop in Maués. The aircraft was carrying two pilots and six passengers.
Approximately 15 minutes before arrival at Eduardo Gomes Airport (SBEG), the crew detected an electrical system failure that disabled emergency lights and prevented the reading of flight instruments. Because the hydraulic pressure indicator was also non-functional, the pilot elected to deploy the landing gear using the emergency selector.
Following the landing, the commander decided to taxi the aircraft to the parking apron rather than remaining on the runway for a tow, as required by company policy. During the taxi, the residual hydraulic pressure—which the manual indicated was only sufficient for approximately 2/25 brake applications—was exhausted. This resulted in a total loss of braking capability and nosewheel steering. The aircraft subsequently collided with a concrete pillar of an airport building, causing severe damage to the airframe and minor damage to the structure. All eight occupants escaped the aircraft uninjured.
The investigation
CENIPA's investigation focused on the decision-making process following the electrical failure. Investigators examined the aircraft's maintenance records, noting it had undergone a major inspection only 80 flight hours prior. The investigation also reviewed the crew's training records, finding that while the pilot was highly experienced, the co-pilot had not completed the company's required simulator training, and neither pilot had participated in recent recurrent training or procedural updates.
Findings
- Inadequate decision-making: The commander chose to taxi the aircraft despite the hydraulic system being in the emergency position, violating both company regulations and the aircraft's emergency procedures.
- Loss of control: The exhaustion of residual hydraulic pressure led to the loss of both brakes and steering.
- Human factors: The crew failed to perform a specific briefing regarding post-landing procedures. The commander's decision was influenced by complacency and a desire to avoid the operational inconvenience of requesting a tow.
- Deficient training and supervision: The airline failed to provide adequate recurrent training and Crew Resource Management (CRM) training, and the co-pilot had not completed required simulator sessions.
- Operational error: The crew did not follow the established protocol to remain on the runway and await a tow after an emergency gear deployment.