Date & Time: Feb 7, 2009 at 1324 LT
Operator:
Registration:
PT-SEA
Survivors:
Yes
Schedule:
Coari - Manaus
MSN:
110-352
YOM:
1981
Country:
Brazil
Crew on board:
2
Crew fatalities:
2
Pax on board:
26
Pax fatalities:
22
Other fatalities:
0
Total fatalities:
24
Captain / Total flying hours:
18870
Captain / Total hours on type:
7795
Copilot / Total flying hours:
1011
Copilot / Total hours on type:
635
Aircraft flight hours:
12686
Circumstances:
The twin engine aircraft departed Coari Airport at 1240LT on a charter flight to Manaus-Eduardo Gomes Airport, carrying 26 passengers and two pilots. About 30 minutes into the flight, while cruising at FL115, the crew informed ATC that the left engine failed and elected to divert to the unused Manacapuru Airfield. While approaching runway 08, the aircraft rolled to the left to an angle of 30° then crashed in the Rio Manacapuru. 24 people were killed while 4 passengers were slightly injured.
Probable cause:
The following factors were identified:
- At takeoff from Coari Airport, the total weight of the aircraft was 6,414 kg, which means 744 kg over the MTOW,
- On board were 26 passengers including 8 children while the aircraft was certified for 19 passengers,
- The left engine fuel pump was completely burnt during the accident but it could not be determined if it failed during the flight or not,
- The crew was not sufficiently trained for emergency situations,
- Poor work organisation,
- Lack of supervision from the operator concerning crew's decisions before and during flights,
- Poor crew coordination,
- Lack of crew communication,
- Non compliance with management techniques,
- Incomplete execution of the actions provided by the emergency checklist.
Final Report:
PT-SEA.pdf329.06 KB