What happened
On April 14, 2012, a Beechcraft C-45H, registration PR-BTW, was performing a local flight from the Itanhaém Aerodrome (SDIM) in São Paulo, Brazil. The aircraft was carrying one pilot and three passengers. During the takeoff roll, upon reaching a speed of 80 mph, the aircraft began to drift toward the left. In an attempt to correct this deviation, the pilot applied right rudder pressure with excessive force. During this maneuver, the pilot's right foot became wedged between the two pedals, delaying the necessary corrective input to the left. Consequently, the aircraft exited the right side of the runway and collided with a ditch located in the grass area adjacent to the pavement. The pilot sustained minor injuries, while the three passengers were uninjured. The aircraft suffered severe damage to the fuselage, the right landing gear, and the engine cowlings.
The investigation
CENIPA's investigation focused on the sequence of control inputs and the pilot's recent flight experience. The investigation established that the aircraft was in a proper state of airworthiness, with all documentation, maintenance inspections, and weight and balance limits in compliance. Investigators examined the pilot's flight logs, noting that while the pilot was highly experienced overall, there had been a significant period of inactivity in this specific aircraft type. The investigation also reviewed the regulatory requirements regarding recent flight experience (RBHA 61) in effect at the time of the accident.
Findings
- The primary cause of the runway excursion was the inappropriate application of rudder controls, specifically the pilot's foot becoming stuck between the pedals during a corrective maneuver.
- A lack of recent proficiency in the specific aircraft type likely contributed to the error, as the pilot had flown the C-45H only approximately 7 hours and 40 minutes in the preceding year.
- The pilot had been operating primarily single-engine aircraft during this period, which may have affected the psychomotor skills required for the handling characteristics of this vintage multi-engine aircraft.
- The aircraft was within all operational and maintenance limits at the time of the event.