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Accident description
Last updated: 23 September 2017
Status:Final
Date:Saturday 7 February 2009
Time:13:24
Type:Silhouette image of generic E110 model; specific model in this crash may look slightly different
Embraer EMB-110P1 Bandeirante
Operator:Manaus Aerotáxi
Registration: PT-SEA
C/n / msn: 110352
First flight: 1981
Total airframe hrs:12686
Engines: 2 Pratt & Whitney Canada PT6A-34
Crew:Fatalities: 2 / Occupants: 2
Passengers:Fatalities: 22 / Occupants: 26
Total:Fatalities: 24 / Occupants: 28
Airplane damage: Damaged beyond repair
Location:off Santo António, AM [Rio Manacapuru] (   Brazil)
Phase: En route (ENR)
Nature:Domestic Scheduled Passenger
Departure airport:Coari Airport, AM (CIZ/SWKO), Brazil
Destination airport:Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG), Brazil
Narrative:
An Embraer EMB-110P1 Bandeirante passenger plane, registered PT-SEA and operated by Manaus Aerotáxi, was destroyed when it crashed into the water of Rio Manacapuru. Both pilots and 22 passengers were killed in the accident. Four passengers survived.
The airplane had departed the Amazon city of Coari (CIZ) at 12:40 on a domestic flight to Manaus (MAO). About 13:10, while at FL115, the no. 1 engine flamed out. At 13:15 the crew made a contact with the Area Control Centre (ACC-AZ) reporting on descent for Manaus with twenty persons on board. In reality there were 28 occupants.
The ACC controller instructed the crew to contact Manaus Approach Control. Subsequently, the pilot informed Manaus Approach that they would return to Coari. Contact was lost and at 13:24 radar contact was lost. The airplane came down in Rio Manacapuru.

The airplane involved, an EMB-110P1, has a (certificated) maximum number of passenger seats of nineteen. On the accident flight 26 passengers had boarded the flight, including eight small children. Maximum takeoff weight for an EMB-110P1 is 5670 kg. The actual takeoff weight of the accident aircraft was 6414 kg.

Probable Cause:

Contributing Factors
1 Human Factor
1.1 Medical Aspect
It did not.
1.2 Psychological Aspect
1.2.1 Individual information
1.2.1.1 - Attitude - undetermined
It is possible that the pilot's stated experience in this type of mission has influenced his permissive attitude towards situations contrary to what was predicted, raising his confidence in the ability to fulfill the mission, thus disregarding the risks involved.
1.2.1.2 - Culture of the working group - contributed
There were no mass pilots conducting standardized procedures, such as briefing before and after each mission. They also showed an attitude of acceptance regarding the pilot's behavior not to carry out the intended procedures. Thus, attitudes were translated into informal rules of behavior in situations related to professional activity and safety.
1.2.2 Organizational Information
1.2.2.1 - Characteristics of the task - undetermined
It is possible that the co-pilot took most of the flight preparation tasks in Coari, since it was customary for this to happen on missions with this commander. This may have interfered with the tasks under their responsibility, such as checking the number of people on board and giving passengers guidance on normal and emergency procedures. In addition, it is possible that the division of tasks relating to emergency procedures has been compromised, considering that some switches have been found in positions contrary to those recommended by the operations manual.
1.2.2.2 - Organizational Culture - contributed
The company culture was reported as being focused on operational safety, however, in practice, what could be verified did not strengthen safe behaviors. Management did not supervise attitudes and did not control compliance with the procedures covered in the Operations Manual and in company training. There was a small participation of its crew members in prevention activities programmed by the company itself.
1.2.2.3 - Training, training and training - contributed
There was no periodicity in training for emergency procedures. Despite the great experience of the commander, the lack of emergency training was present. Training of normal procedures, such as passing proper instructions to passengers, has also not been verified.
1.2.2.4 - Organization of work - contributed
The procedures foreseen and established in the company's Operations Manual for operational safety were not applied, since the crew stopped transmitting the verbal instructions to the passengers, before takeoff and in the emergency situation.
The crew made it possible to take off with excess weight and passengers, stopped communicating the emergency situation to the air traffic control agencies and allowed passengers to drink alcohol during the flight, facts that prove the accomplishment of the activities in an improvised way.
1.2.3 - Organizational processes - contributed
1.2.3.1 - Support systems - contributed Through the policy of granting total autonomy to the commander, the company was unaware of the decisions which, consequently, could affect the safety of the flight, as happened in relation to the refueling of the aircraft with less fuel And embark passengers in excess, thus demonstrating that there was no monitoring of activities in the operational scope.
1.2.3.10 - Other - contributed
The blockage in the flow of information when the crew omitted information to Air Traffic Control and the lack of information to the passengers, during all the phases of the mission, made the assistance difficult in the face of the situation experienced, because if they had been The consequences could have been minimized.
1.3 Operational Aspect
1.3.1 Maintenance of the aircraft - contributed
If the company's maintenance sector had performed the Oil Fuel Heater temperature check, it probably could have been verified that the thermal element had failed, which would lead to the replacement of the assembly, as recommended by the engine manufacturer's maintenance manual. It can not be said that such a failure was decisive for the engine failure, but evidenced an inadequate maintenance.
1.3.2 Application of commands - contributed
It is likely that the pilot did not use the correct pilot technique for the single-engine flight maintenance procedure in accordance with the manufacturer's Operations Manual.
1.3.3 Cabin coordination - contributed
The final consequences of the event were aggravated by the inefficient use of available cabin resources, reflected in the poor communication with the control bodies, lack of verbal emergency information to passengers, incomplete implementation of the actions foreseen in the list of emergency procedures and inadequate piloting techniques.
1.3.4 Pilot trial - contributed
The acceptance of the crew to operate the aircraft above the weight and passenger limits without considering the possibility of an emergency situation, such as one of the engines, was a contributing factor in making the flight unfeasible.
1.3.5 Flight planning - contributed
There was a failure in the flight planning with regard to the over weight of takeoff, since the possibility of an emergency due to engine failure was not considered, being configured in a contributing condition to the event.
1.3.6 Management oversight - contributed
Company oversight was inadequate because of deficiencies in training, as well as for granting excessive autonomy to commanders and for not establishing mechanisms to control, monitor and manage operational activities.
1.3.7 Flight Discipline - contributed
The crew has not complied with the procedures of the General Operations Manual (MGO) and the Operations Manual of the aircraft manufacturer. The lack of verbal information for passengers, over-weight and passenger take-off, the concealment of the emergency for the control bodies and the lack of preparation of the passengers, regarding the emergency procedures, put the flight and Culminated in the process of irreversibility of the accident.
1.3.8 Other operational aspects - contributed
The supervision of the Civil Aviation Authority is an important instrument to ensure compliance with the safety standards. Thus, the lack of adequate supervision at the Coari aerodrome contributed to the aircraft taking off with excess weight and passengers.
The company also failed to oversee compliance with its own General Operations Manual (MGO) or limitations imposed by the manufacturer, which allowed deviations that compromised flight safety and led to the accident.
2 Material Factor
2.1 Manufacturing - undetermined
It is possible that the failure of the thermal element of the fuel heater occurred due to a deficiency in the material used.
2.2 Material Handling - undetermined
It is possible that the thermal element failure of the fuel heater has occurred due to improper handling during the manufacturing process.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 1 year and 2 months
Accident number: A-018/CENIPA/2010
Download report: Final report

Classification:
Overloaded

Forced landing outside airport

Sources:
» Avião com 24 pessoas cai em rio do Amazonas, 4 sobrevivem (O Globo, 7-2-2009)
» Manaus Aerotáxi
» Força Aérea Brasileira


Follow-up / safety actions

CENIPA issued 16 Safety Recommendations
SERIPA VII issued 2 Safety Recommendations

Show all AD's and Safety Recommendations

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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Coari Airport, AM to Manaus-Eduardo Gomes International Airport, AM as the crow flies is 362 km (226 miles).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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