AVIATION/ BRAZIL REPORTS ON MANAUS AEROTAXI CRASH

The Brazilian agency charged with investigating aviation accidents, CENIPA, has released its Final Report into the crash of an MANAUS AEROTAXI Embraer 110 Bandeirante near Santo Antonio, Brazil, on February 7, 2009. The Bandeirante was on Domestic Service from Coari to Manaus, Brazil, with 26 passengers and 2 Pilots onboard, and departed Coari at 12:40pm. About 1 hour after departure, the Pilot contacted ATC and stated that he was going to return to Coari. No futher communication was transmitted from the flight. The Bandeirante went down about 1:50pm into the Manacapuru River, a tributary of the Amazon River. Of those onboard, 22 of the 26 passengers, and both Pilots, were killed in the crash. The 4 survivors suffered minor injuries. At the time of the crash, a Civil Defense Coordinator told O Coariense, a Coari newspaper, that the plane was trying to make an emergency landing on a make-shift landing strip. "The survivors said they saw one of the plane's motors shut down. We thought he would try to land on a deactivated landing strip but he couldn't make it". In their final report, CENIPA stated the following as fact:

a) The flight from Coari to Manaus took off at 12:40pm.
b) The takeoff weight was 6414kg (14128lbs).
c) At 1:15pm, the crew contacted the Amazonic Area Control Center reporting to be at 11500ft and beginning the descent.
d) The Pilot reported 20 people onboard the aircraft, when in reality there were 28 people onboard.
e) The Pilot reported to Approach Control Manaus they would return to Coari but continue to descend via a slight right exit route towards the runway of Manacapuru.
f) The aircraft impacted the river 39.5nm west of Manaus and submerged soon after.
g) 22 passengers and 2 crew died, 4 passengers were rescued with minor injuries.
h) The aircraft was enroute when the left hand propeller stopped spinning about 30 minutes into the flight
i) The weight of the aircraft at the time of the accident was estimated at 6219 kg (13700 lbs).
j) Tests revealed the left hand engine developed no power.
k) The right hand engine showed evidence of operability.
l) The electronics of the left hand main electrical fuel pump was found burned, it could not be determined whether the damage occurred in flight or post impact.
m) The fuel pump never ran dry demonstrating the existance of fuel in the left wing fuel tank before impact with water.
n) A discrepancy was identified in the starter controller that could have caused a slower than normal engine start up soaking the plugs and causing a failure of startup.
o) The left hand mechanical fuel pump produced a lower output pressure than expected due to erosion in the fuel outflow area.
p) The heating element of the left hand "Oil Fuel Heater" was stuck in the open position.
q) All switches of the electrical fuel pumps were in the position "connected".
r) There was a layer of low cloud near the runway of Manacapuru.
s) The aircraft, already near the threshold of runway 08, drifted off to the left and impacted the water.
t) The aircraft impacted water with a 30 degrees left hand bank angle (left wing impacting water first), subsequently the nose struck the water.
u) There was no preparation of the passengers for emergency procedures preceding the flight or inflight during preparation for the emergency landing.

In the report, CENIPA blames the crash on multiple errors made by the crew. The report notes that the Captin had little experience with abnormal procedures and did not apply the correct handling technique for single engine operation in accordance with the operating manual. CENIPA also notes that the Bandeirante was overweight at the time of takeoff and that the passengers were not briefed in emergency procedures. The overweight departure played a role in how the aircraft performed after suffering engine failure while enroute. Since the aircraft was overweight, continued flight after the engine failure was deemed as impossible. The full report, in Portugese, can be found on the CENIPA website.