Status: | Accident investigation report completed and information captured |
Datum: | dinsdag 17 oktober 2017 |
Tijd: | 10:40 |
Type: | Cessna 208 Caravan I |
Luchtvaartmaatschappij: | Greenpeace Brasil |
Registratie: | PR-MPE |
Constructienummer: | 20800510 |
Bouwjaar: | 2009 |
Motoren: | 1 Pratt & Whitney Canada PT6A-114A |
Bemanning: | slachtoffers: 0 / inzittenden: 1 |
Passagiers: | slachtoffers: 1 / inzittenden: 4 |
Totaal: | slachtoffers: 1 / inzittenden: 5 |
Schade: | Groot |
Gevolgen: | Written off (damaged beyond repair) |
Plaats: | Rio Negro, Parque Nacional de Anavilhanas, AM ( Brazilië)
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Fase: | Landing (LDG) |
Soort vlucht: | Onderzoek |
Vliegveld van vertrek: | Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG), Brazilië |
Vliegveld van aankomst: | ? |
Beschrijving:A float-equipped Cessna 208 Caravan I, operated by Greenpeace Brazil, suffered an accident while attempting to land on the Rio Negro river in the Anavilhanas National Park near Manaus in Brazil. The aircraft touched the water with its landing gear extended and it overturned. One of the passengers sustained fatal injuries.
Probable Cause:
2 Contributing factors.
- Attitude - a contributor.
Failure to comply with the checklist during the pre-flight inspection and the flight itself favored the landing with inadequate configuration. This attitude may have been triggered by the pilot's confidence in his operational capability, because of his long experience in aviation.
- Flight indiscipline - a contributor.
Failure to comply with the checklist indicated, in addition to the low level of situational awareness, a low level of concern for the safe conduction of the flight by failing to follow basic procedures set forth in the manufacturer's manuals and current regulations.
- Piloting judgement - a contributor.
The pilot's choice not to use the checklist during the flight phases revealed an inadequate evaluation of parameters related to the operation of the aircraft. Improper compliance with the items in the Pre-Flight Inspection Sheet prevented the AMPHIB PUMP 1 and 2 circuit breakers from being rearmed.
- Aircraft maintenance - a contributor.
After performing the test of landing gear extension and retraction by the emergency system, the AMPHIB PUMP 1 and 2 circuit breakers were not rearmed, being the aircraft delivered to fly in this condition The setting recorded on the AIRSPEED switch of the landing gear position warning system computer demonstrated that the scheduled speed of 74kt was not in accordancewith the recommended in the 9600-1A installation manual of Wipaire Inc. in its revision G.
- Memory - undetermined.
The AMPHIB PUMP 1 and 2 circuit breakers were found disarmed after the occurrence, indicating that, after the completion of the maintenance service, the executor of the tasks probably forgot to comply with the procedures for reconfiguring the aircraft. In addition, it is possible that the pilot's automatism in relation to his way of carrying out the air operations, without the use of the checklist, has prevented the correct perception of the circuit breakers condition and the erroneous positioning of the landing gear.
- Perception - a contributor.
The accomplishment of the landing on the water with the aircraft in inadequate configuration for the situation denotes a decrease in the level of situational awareness of the pilot, considering that the necessary factors and conditions for the safety of the operation were not observed.
Accident investigation:
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Investigating agency: | CENIPA Brazil |
Status: | Investigation completed |
Duration: | 1 year and 8 months | Accident number: | A-131/CENIPA/2017 | Download report: | Final report
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Bronnen:
»
greenpeace.org»
Avião do Greenpeace cai no Rio Negro com cinco passageiros a bordo (acritica.com, 17 Oct 2017)» CENIPA preliminary information
Veiligheidsmaatregelen
CENIPA issued 4 Safety Recommendations
Issued: 28-JUN-2019 | To: ANAC | A-131/CENIPA/2017-01 |
Work with Manaus Air Taxi (COM N ° 0701-02/ANAC) to ensure that the maintenance procedures performed by that company on the Wipaire floats, and in the systems related to the operation of this equipment, are in accordance with the manufacturer\'s services manual, in particular with regard to the annual inspections and configurations of the amphibian landing gear position warning system. |
Issued: 28-JUN-2019 | To: ANAC | A-131/CENIPA/2017-02 |
Work with Manaus Air Taxi (COM N ° 0701-02/ANAC) to ensure that the procedures for the preparation of the aircraft performed prior to its release to flight are in accordance with the operating manuals for each equipment, which refers to pre-flight inspections and postinspection checks or maintenance services. |
Issued: 28-JUN-2019 | To: ANAC | A-131/CENIPA/2017-03 |
Work with the representative of Wipaire Inc. in Brazil, in order for the company to analyze the pertinence of updating the service and the installation manual of the Wipline 8000 floats, so that this document brings a routine check the AMPHIB PUMP 1 and 2 circuit breakers in the IN position after executing the extending and retracting check for landing gear emergency. |
Issued: 28-JUN-2019 | To: ANAC | A-131/CENIPA/2017-04 |
Disseminate the lessons learned in this investigation, in order to alert Brazilian civil aviation pilots and operators about the risks arising from the non-use of the checklist, especially in critical flight phases such as landings and take-offs. |
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Foto's
accident date:
17-10-2017type: Cessna 208 Caravan I
registration: PR-MPE
Video, social media
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.