Investigation Summary
The investigation by CENIPA revealed a series of operational violations that directly contributed to the accident. The aircraft departed Coari with 28 people on board, including 26 passengers, which was seven more than its maximum certified capacity and ten more than the number of installed seats. To accommodate the extra occupants, eight children were carried as lap passengers. The pilot intentionally misreported the number of souls on board to air traffic control, stating there were 20 people instead of 28. Calculations post-crash determined the aircraft was 549.7 kg above its maximum takeoff weight. When the left engine failed en route, the aerodynamic performance of the Bandeirante was insufficient to sustain level flight on the remaining engine under such a heavy load. The crew initially informed Manaus Approach that they intended to return to Coari, but as altitude could not be maintained, they attempted to divert to an abandoned runway in Manacapuru. They could not reach it, striking the water instead. The four survivors, all seated in the rear, managed to escape through an emergency exit before the fuselage fully submerged. Investigators also noted a significant breakdown in operational discipline, including the crew allowing passengers to consume alcohol during the flight. Additionally, a maintenance oversight was found: a failed thermal element in the Oil Fuel Heater. While not definitively linked to the engine flameout, the failure to detect this during maintenance was noted as a contributing factor in the organizational and maintenance aspects of the operation.
Final Conclusions
The Aeronautical Accidents Investigation and Prevention Center (CENIPA) concluded that the primary cause was the operation of the aircraft beyond its certified weight and balance limits. The contributing factors included the failure of the left engine and the decision by the crew to take off with an excessive number of passengers, which prevented the aircraft from maintaining a safe altitude on a single engine. The investigation also highlighted the falsification of occupant numbers provided to air traffic control.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Pratt & Whitney Canada PT6A
The twin turboprop engines powering the EMB-110; the left engine failed during flight, necessitating single-engine operation.
Emergency Exit
The rear emergency exit was successfully opened by survivors, allowing them to escape the sinking fuselage.
Interesting Facts
- 01The aircraft was manufactured in 1981.
- 02The aircraft was carrying 28 people but was only certified for a maximum of 21.
- 03The plane was 549.7 kg over its maximum certificated takeoff weight.
- 04There were only 18 passenger seats installed; eight children were carried on laps.
- 05All 24 fatalities were caused by drowning rather than impact trauma.
- 06The four survivors were all seated in the rear of the aircraft.
- 07The aircraft's serial number (MSN) was 110352.
- 08CENIPA found a failed thermal element in the Oil Fuel Heater that had not been identified during maintenance.
Safety Actions & Advisories
Weight and Balance Oversight
The investigation emphasized the necessity for strict adherence to maximum takeoff weights and passenger seating configurations, particularly in air taxi operations.