What happened
On August 20, 2001, a C-320C operated by TACA (Táxi Aéreo Cândido Ltda) departed Belém, Brazil, bound for Breves, Pará. The flight was intended to transport engine lubricant to Breves, with a return leg planned to carry passengers. The pilot was the sole occupant of the aircraft.
At approximately 11:38 AM, the pilot established his final contact with Belém ACC, requesting permission to descend and land in Breves. Witnesses on the ground, including the aircraft owner, observed an aircraft matching the description of PT-CGI flying at a high altitude in a banking turn, showing no signs of an approach. Shortly thereafter, the aircraft was located 14 nautical miles northeast of Breves in a heavily wooded, swampy area. The impact occurred in a steep, nearly vertical dive of approximately 120 degrees, causing the aircraft to bury itself roughly 1.5 meters into the ground. The aircraft was destroyed, and the pilot sustained fatal injuries at the scene.
The investigation
CENIPA investigators examined the aircraft's maintenance records, which were found to be up to date and compliant with periodic inspections. The pilot held valid commercial licenses and a medical certificate. Meteorological conditions during the flight were favorable, with visibility exceeding 10 km and minimal cloud cover.
Investigators focused on a head injury the pilot had sustained earlier that morning when a baggage compartment door struck him. Although the pilot received medical treatment and a bandage, he did not report the incident to his employer. Witnesses noted that the pilot had expressed feeling dizzy and unwell to colleagues prior to the flight. The investigation also analyzed the impact dynamics, noting that the aircraft's landing gear and flaps were retracted, suggesting a high-energy, uncontrolled descent.
Findings
- Human Factors (Psychological): The pilot's excess of self-confidence and poor decision-making led him to proceed with the flight despite not being in optimal physiological condition.
- Human Factors (Physiological): It is possible the pilot experienced a sudden medical event in flight, potentially resulting from the previously sustained mild cranial trauma.
- Operational Factors: There was a lack of effective supervision, as company management failed to intervene or prevent the flight after the pilot had been injured and reported feeling unwell to peers.
Safety action
CENIPA issued several recommendations to the operator, TACA, including the implementation of more active supervision and the establishment of clear procedures to ensure crew members feel empowered to declare themselves unfit for flight due to physical or psychological health concerns. Additionally, the agency recommended that the operator conduct regular safety training and lectures regarding the SIPAER philosophy to foster a robust safety culture.