Narrative:A Cessna 208B Grand Caravan was destroyed in an accident near Manaus-Aeroclube de Flores, AM. The pilot, the sole occupant, sustained fatal injuries.
The airplane took off from runway 29 on a ferry flight to Manaus-Eduardo Gomes International Airport, AM (MAO). It failed to gain enough height on takeoff and collided with a pole. The airplane came down in a wooded area just off Avenida Torquato Tapajós.
Manaus-Aeroclube de Flores Airport, AM has a single, 860 m long asphalt runway.
It appeared that the control locks were still in place and had not been removed during the preflight checks.
a) Attitude - unspecified
To assume all the responsibilities of flight (flight notification, removal from the aircraft, inspections, etc.) almost alone, the pilot showed overconfidence in his ability to perform such a task, possibly considering it ordinary and of low complexity.
In addition, the company mechanic's participation in the preparation of the aircraft may have strengthened the confidence that the pre-flight items that may pass unnoticed would be performed by one technician.
b) Memory - contributed
The pilot forgot the control lock on the aircraft, which may have resulted from the rush to do the checklist, in which some items were not checked properly, as the existing lock model, which was less visible and was not approved for aeronautical purposes.
c) Motivation - contributed
The commander proved to be very motivated to make the supply flight quickly, so as not to impair the subsequent flight, which may have interfered with the completion of the checklist so that culminated in lock remaining in place.
a) Team Dynamics - contributed
Although the pilot relied on mechanical help in the preparation of the aircraft, the dynamic established by them did not guarantee the execution of the tasks efficiently and safely.
a) Organizational culture - contributed
The company since two years used a non-approved control lock and there was no standardization of the procedures of company manuals, which indicates that the fragile safety culture that reverberated in the accident.
b) Support Systems - contributed
The manuals of the company not clearly specified the activities that the mechanic should follow when preparing the aircraft, thus allowing gaps were created in the execution of the task.
Concerning aircraft operation
a) Cockpit coordination - contributed
The pilot in command stopped using organizational resources available to him to accomplish the task to transfer the aircraft. The copilot had not arrived and the mechanic of the company was not among its duties to perform the complete pre-flight aircraft. Thus, the commander had to perform various tasks in a relatively short time and, therefore, failed to comply with an important item in the checklist that was removal of the lock of flight controls.
b) Pilot forgetfulness - contributed
The pilot forgot to remove the control lock during inspections (internal and external). Also forgot to perform the checklist of items relating to freedom of controls (aileron and elevator), during taxi the aircraft. The realization of these checks during pre-flight or even in the taxi the aircraft would have avoided the takeoff and, therefore, the accident.
c) Managerial supervision - contributed
Inadequate supervision of maintenance management allowed the aircraft involved in the accident to possess control locks not certified as an aeronautical product.
d) Non-standard procedure - contributed
The pilot, possibly due to the rush to perform takeoff, failed to meet a number of items set out in checklist that, if realized, would alert the commands that the lock had not been removed. This item can be considered as the last barrier to prevent the accident.
Loss of control
Official accident investigation report
|investigating agency: ||Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) - Brazil |
|report status: ||Final|
|report number: ||A-626/CENIPA/2014|
|report released:||15 May 2015|
|duration of investigation: ||3 years and 3 months|
|download report: ||
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-Aeroclube de Flores Airport, AM to Manaus-Eduardo Gomes International Airport, AM as the crow flies is 5 km (3 miles).