What happened
On March 11, 2023, a Cessna R182, registration PT-FLK, was performing a private flight from Morada Nova de Minas to Belo Horizonte. During the approach to Carlos Prates Aerodrome (SBPR), the pilot attempted a landing that resulted in a runway excursion.
Surveillance footage revealed that the pilot initially attempted a landing but performed a go-around. During the second landing attempt, the aircraft touched down 180 meters short of the runway's far threshold with the landing gear in the retracted position. The aircraft continued down the runway, overran the departure end, and impacted two residential structures located beyond the aerodrome limits. The accident resulted in one fatality (the pilot) and one serious injury (the passenger). The aircraft sustained substantial damage.
The investigation
CENIPA's investigation focused on the pilot's medical fitness and operational procedures. Investigators found no evidence of mechanical failure, noting that the aircraft's maintenance records were up to date and the engine and propeller were in good condition.
Analysis of the wreckage confirmed the landing gear control lever was in the "UP" position. Medical examinations of the pilot revealed the presence of barbiturates in his system, specifically metabolites from Primidone, a medication used to treat epilepsy. The investigation also noted that the pilot was not wearing the corrective lenses required by his medical certificate. Furthermore, the pilot's flight logs in the official system did not accurately reflect his recent flight experience, although observers suggested he was a frequent flyer in the region.
Findings
- The pilot was operating under the influence of medication incompatible with aviation activities.
- The landing gear was not extended for the second landing attempt due to potential cognitive impairment or memory lapse.
- The pilot failed to initiate a go-around despite an excessively long landing roll.
- The pilot's decision-making was compromised by emotional stress and the physiological effects of medication.
- The pilot was not using required corrective lenses during the flight.