What happened
On January 11, 2001, an EMB 820C – Navajo, operated by Bahia Táxi Aéreo (BATA), departed from Ilhéus, Bahia, en route to Jequié, Bahia. The flight was intended to be a visual flight rules (VFR) operation to transport bank mailbags. Upon reaching the vicinity of Jequié, the crew encountered prohibitive weather conditions, including thick fog and extremely low ceilings of approximately 30 meters with visibility restricted to 200 meters.
Unable to proceed with a visual approach to the destination, the crew navigated toward the Pedra Dam region, seeking better conditions. Witnesses observed the aircraft flying at a low altitude over the water. During a maneuver near the dam, the aircraft struck treetops at a low angle before colliding with the rising terrain. The impact was severe enough to cause the aircraft to lose its left wing and undergo a continuous ground slide for approximately 200 meters. The aircraft was destroyed by the impact and a subsequent intense fire.
Both crew members sustained fatal injuries. The pilot died at the scene, and the co-pilot succumbed to severe burns later that day.
The investigation
CENIPA's investigation focused on the decision-making process of the crew and the environmental factors present at the time of the accident. The investigation established that the aircraft was in a proper maintenance status, with all certificates and inspections up to date. The crew members were both highly qualified, with the pilot possessing significant experience and a valid Airline Transport Pilot License.
Investigators examined the operational procedures, noting that while the operator had a system in place for crews to verify local weather via telephone, the crew did not utilize this service for the Jequié leg. The investigation also analyzed the flight path, suggesting the crew may have been attempting to use the surface of the dam as a visual reference to navigate through the low clouds, a maneuver that ultimately led to a Controlled Flight Into Terrain (CFIT) event.
Findings
- Adverse meteorological conditions prevented a safe visual approach and influenced the decision to descend to low altitudes near the dam.
- Improper judgment led the crew to continue the flight under VFR rules when conditions had become entirely unsuitable for visual navigation.
- Flight indiscipline was noted as the crew opted to fly at low altitudes in an attempt to maintain visual contact with the ground despite the lack of visibility.
- Excessive confidence in the pilot's experience contributed to a failure in risk assessment and decision-making.
- Lack of coordination in the cockpit likely prevented a timely reversal of the flight path.
Safety action
Following the investigation, CENIPA issued several safety recommendations:
- The regional aeronautical authority (SERAC 2) was directed to conduct a flight safety inspection of Bahia Táxi Aéreo and hold safety lectures regarding the accident.
- The operator was required to disseminate the report's findings to all crew members, specifically focusing on weather analysis, flight discipline, and adherence to air traffic rules.
- The operator was instructed to implement Crew Resource Management (CRM) training for its flight crews.