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Last updated: 3 December 2020
Status:Final
Date:Monday 21 April 2008
Time:15:00
Type:Silhouette image of generic E110 model; specific model in this crash may look slightly different
Embraer EMB-110P1 Bandeirante
Operator:Rico Linhas Aéreas
Registration: PT-OCV
C/n / msn: 110359
First flight: 1981
Engines: 2 Pratt & Whitney Canada PT6A-34
Crew:Fatalities: 0 / Occupants: 2
Passengers:Fatalities: 0 / Occupants: 15
Total:Fatalities: 0 / Occupants: 17
Aircraft damage: Damaged beyond repair
Location:Coari Airport, AM (CIZ) (   Brazil)
Phase: Landing (LDG)
Nature:Domestic Scheduled Passenger
Departure airport:Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG), Brazil
Destination airport:Carauari Airport, AM (CAF/SWCA), Brazil
Narrative:
Some fifty minutes after takeoff from Manaus, Brazil, at an altitude of FL085, the right-hand engine failed. The propeller was feathered and the flight crew decided to divert to Coari Airport, AM (CIZ).
After touching down on runway 28, the pilot lost directional control and the aircraft slid off the runway.
It traveled about 200 meters until it passed through a ditch, which caused the landing gear to break.

Probable Cause:

Contributing factors
1 Human factor
1.1 Medical aspect
Nothing to report.
1.2 Psychological aspect
a) Attitude - contributed
At the individual level, there was the participation of psychological variables that directly influenced the conduct of the flight, mainly in relation to the disregard with procedures for the safe operation of the aircraft, evidenced by the overweight take-off and the non-use of the checklist during the emergency procedures. This non-compliance with the procedures was combined with the overconfidence presented by the pilot for having extensive experience in the aircraft.
b) Decision making process - contributed
The decision making, in this context, was random, and there was no consultation with the mechanic for the knowledge of the real conditions of the aircraft; in addition, the information available to perform a safe flight was not considered.
c) Crew dynamics - contributed
There was no integration of the team during the emergency procedures, which led to the omission of reading the checklist.
d) Training, capacity building and training - contributed
At the organizational level, the company was not equipped with an effective personnel training system, as a result of which, as noted, the crew did not have sufficient skills for emergency situations.
1.3 Operational aspect
a) Command Application - contributed
As the aircraft was overweight, in single-engine flight condition, it needed more speed for approach and landing.
The lack of proper use of the controls made it possible to touch the runway about 700 meters after the threshold, leaving a very reduced distance for the controlled reduction of speed and total stop of the aircraft.
b) Cabin Coordination - contributed
The great difference in experience and qualification between the pilots prevented the co-pilot from taking a more proactive position. The crew focused their attention on the occurrence of the engine failure, not noticing the electrical breakdown, which delayed the distribution of tasks, all aggravated by not using the check list.
c) Pilot forgetfulness - contributed
The failure to read the check list for the emergency lowering procedure contributed to forgetting the necessary return of the selector to the normal position, which in turn contributed to the loss of control of the aircraft on the ground after landing.
d) Flight Discipline - Contributed
There was an intentional disobedience of the crew with respect to the operational standards established by the aircraft manufacturer (overweight).
e) Infrastructure - contributed
About 30m from the side of the runway, there was a depression caused by rain erosion, in which the aircraft, after leaving the runway, suffered the collapse of the landing gears.
f) Instruction - contributed
The crew was focusing their attention on the breakdown of engine 2 and the consequent single-engine landing. When faced with the impossibility of lowering the undercarriage through the normal system, it probably had its stress level increased. The Co-Pilot reported difficulties in locating the checklist, which ended up not being used, leading to other operational failures: not repositioning the selector switch in the "normal" position after the undercarriage was lowered by the emergency system. This fact denotes the lack of training in emergency situations.
g) Trial of pilotage - contributed
The crew did not adequately assess the condition of the aircraft, which operated single-engine and overweight and would lead to different speed parameters for approach and landing.
(h) Maintenance of the aircraft - contributed
The state of the mechanical fuel pump showed lack of maintenance and excessive use (possible exceeded limits), proven by the presence of iron oxide in the external and internal part, as well as the lack of cleaning of internal components.
i) Support staff - contributed
The support staff of the airline, responsible for preparing the aircraft for weight planning and balancing, allowed the operation with the weight above the expected limits.
j) Flight planning - contributed
There was inadequate preparation for the flight when the crew stopped considering the total number of passengers and filled the aircraft completely, causing the excess weight that contributed to the difficulty of controlling the aircraft in single-engine conditions, causing the long landing and aggravating the situation.
k) Management supervision - contributed
The supervision did not occur in an adequate way, mainly in the maintenance activity. The company did not comply with the standards recommended in aviation in order to supervise the execution of the maintenance services performed. In the operational area, the aircraft was allowed to operate above the maximum take-off weight.
2 Material factor
Nothing to report.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 2 years
Accident number: A-031/CENIPA/2010
Download report: Final report

Classification:
Overloaded

Forced landing on runway

Sources:
» FAB recolhe caixa-preta de avião que derrapou no AM (Globo, 22-4-2008)


Follow-up / safety actions

CENIPA issued 9 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 Manaus-Eduardo Gomes International Airport, AM to Carauari Airport, AM as the crow flies is 783 km (489 miles).
Accident location: Approximate; accuracy within a few kilometers.

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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