What happened
On February 7, 2018, a Beechcraft F35, registration PT-AVO, departed from an unregistered gravel runway in the Crepurizão community, located in Itaituba, Pará. The flight was intended to transport cargo and personnel to the Presidente João Batista Figueiredo Aerodrome in Sinop, Mato Grosso.
Witnesses reported that immediately after takeoff, the aircraft entered an aggressive climb followed by a sharp left turn. During this maneuver, the aircraft lost altitude and struck the ground near the edge of a water reservoir, approximately 280 meters from the runway threshold. The impact, which occurred while the engine was still producing power, resulted in a post-crash fire that destroyed the aircraft. The pilot and two passengers sustained fatal injuries.
The investigation
CENIPA's investigation established that the aircraft was within its weight and balance limits and possessed a valid airworthiness certificate. However, investigators noted several regulatory discrepancies, including the use of an unregistered runway that had been officially canceled in 2007 and the fact that the pilot's medical certificate (CMA) had been expired since November 2017.
Evidence from the scene and video footage indicated that the pilot frequently performed low-level passes and acrobatic maneuvers in the area. Investigators analyzed the flight path and concluded that the aircraft's trajectory after the turn was consistent with the intended route to the destination, suggesting the accident was likely triggered by the specific maneuvers performed during the takeoff phase.
Findings
- Improper use of flight controls: The aircraft may have been placed in an attitude that caused a loss of lift due to low airspeed and a steep bank angle, leaving insufficient altitude for recovery.
- Inappropriate pilot attitude: A pattern of excessive self-confidence and exhibitionism likely influenced the adoption of high-risk parameters during takeoff.
- Judgment and decision-making: An inadequate assessment of the aircraft's maneuverability and limitations may have led to a flight profile incompatible with safe operations.
- Work-group culture: Local informal practices and a shared culture of non-compliance with aviation regulations contributed to a higher level of risk-taking.
Safety action
CENIPA issued the following recommendations to Brazil’s National Civil Aviation Agency (ANAC):
- Take action in the Crepurizão district to inhibit the use of the unregistered aerodrome to prevent accidents caused by inadequate infrastructure.
- Disseminate the lessons learned from this investigation to alert pilots and operators regarding the necessity of respecting aircraft performance limits.