What happened
On January 31, 2000, an EMB-110 P1, registration PP-EAM, operated by the Government of the State of Amazonas, departed Tefé, Brazil, with 19 people on board. Although the flight plan specified Eirunepé as the destination, the crew diverted to an unregistered and uncertified landing field in Envira.
Upon arrival in Envira, the area was experiencing heavy rainfall and low visibility. The crew performed a holding pattern to wait for weather improvements before attempting a landing. The aircraft approached the runway with a high descent angle and landed approximately 500 meters past the threshold. Despite the application of maximum braking and reverse thrust, the aircraft could not stop on the wet concrete surface. The aircraft overran the end of the runway, crossed a protective fence, and came to rest in a nearby pond. The pilot sustained serious injuries, while the co-pilot and 17 passengers were uninjured.
The investigation
CENIPA's investigation revealed that the aircraft was operating significantly above its certified weight limits. The estimated takeoff weight was approximately 6,091.7 kg, exceeding the maximum allowable takeoff weight of 5,670 kg. The estimated landing weight was also above the 5,450 kg limit.
The investigation examined the crew's decision-making and operational procedures. It was noted that the crew had previously landed at this uncertified location. Furthermore, the investigation found that the crew failed to perform a landing briefing or standard call-outs. There was also evidence of poor Crew Resource Management (CRM), characterized by a lack of effective communication between the pilot and co-pilot, including an instance where the co-pilot retracted the flaps without authorization.
Findings
- Improper Weight Management: The aircraft was operating in an overweight condition due to excessive fuel loading intended to provide extra reserves.
- Unsafe Landing Conditions: The landing occurred on a wet, uncertified runway during heavy rain, which likely led to hydroplaning.
- Operational Deviations: The crew deviated from the filed flight plan to land at an unauthorized airfield and failed to follow standard approach procedures.
- Human Factors: The pilot's decision-making may have been compromised by overconfidence. Additionally, poor coordination and lack of communication between the crew members contributed to the accident.
- Lack of Oversight: The operator failed to provide adequate supervision, allowing the use of uncertified landing sites and operations exceeding manual weight limits.