What happened
On November 4, 2009, a Cessna U206F, registration PT-JOE, was involved in a loss of control accident at Fazenda Maria Bonita, in Eldorado dos Carajás, Pará. The flight was part of an emergency evacuation of employees and their families from a farm facing an invasion by the MST (Landless Workers' Movement).
After landing at the unregistered farm airstrip to pick up seven passengers, the pilot performed a 180-degree turn and prepared for takeoff. Due to the presence of protesters at the opposite end of the strip, the pilot chose to take off facing uphill. During the takeoff roll, the pilot noticed the aircraft was not gaining sufficient speed. In an attempt to achieve a shorter takeoff, the pilot increased the flap setting from 10 to 20 degrees and rotated the aircraft at a speed of less than 60 knots. Upon leaving the ground, the aircraft lacked sufficient lift and descended into a depression approximately 400 meters ahead of the runway, resulting in a heavy impact and the aircraft flipping onto its back. The impact caused severe damage to the airframe, engine, and propeller. The pilot and one passenger sustained minor injuries, while the remaining six passengers were uninjured.
The investigation
CENIPA's investigation established that the takeoff was conducted on a deteriorated, unregistered, and uncertified airstrip. The investigation found that the pilot was operating under significant psychological pressure due to the ongoing land conflict. While the pilot was qualified and experienced, the decision-making process was compromised by the need to evacuate passengers quickly. The investigation also noted that the aircraft's weight and the uphill takeoff direction required a longer runway than was available, especially given the poor surface conditions. Furthermore, the company management had planned the evacuation without considering the operational limitations of the aircraft or the risks associated with the uncertified landing site.
Findings
- Improper takeoff configuration: The pilot attempted a rotation at a low speed using 20 degrees of flaps to force a short takeoff, which brought the aircraft dangerously close to its stall speed.
- Inadequate runway assessment: The pilot failed to account for the uphill gradient and the deteriorated condition of the strip, which increased the required takeoff distance.
- Operational pressure: The flight was planned under emergency circumstances, leading to a lack of proper consideration for aircraft performance limits and environmental factors.
- Management failures: The company's management failed to provide adequate supervision and allowed the evacuation to proceed using an uncertified strip and an overloaded configuration without proper risk assessment.
- Regulatory non-compliance: The operation utilized an unregistered and uncertified airstrip, violating aviation regulations.