What happened
On December 7, 2008, a Maule M-7-235 seaplane, registration PT-ONN, departed from the Igarapé do Tarumã in Manaus, Brazil, for a visual flight to Manacapuru. The aircraft was carrying the pilot and four passengers. Shortly after departing from the water, the pilot executed a left turn and attempted to climb to clear an elevation of approximately 450 feet.
During the maneuver, the aircraft entered an abnormal attitude and lost control. Approximately two minutes after takeoff, the aircraft struck trees on the right bank of the Igarapé da Cobra. The impact resulted in the death of the pilot and caused serious injuries to two passengers and minor injuries to two others. The aircraft was destroyed.
The investigation
CENIPA's investigation established that the aircraft was operating significantly outside its certified performance envelope. The takeoff weight was recorded at 3,400 lb, which exceeded the maximum allowable takeoff weight of 2,750 lb for the aircraft when equipped with AQUA 2400 floats by 650 lb. Furthermore, the weight distribution was improper; the center of gravity (CG) was located at 24.4 inches, well beyond the manufacturer's aft limit of 20 inches.
The investigation also revealed that the pilot's medical certificate had expired and the aircraft's airworthiness certificate was suspended. Maintenance records were also found to be outdated. Investigators noted that the pilot's decision-making was influenced by several human factors, including fatigue from insufficient rest and a high level of motivation related to potential future employment opportunities.
Findings
- Overweight takeoff: The aircraft was 650 lb over its maximum takeoff weight.
- Improper weight and balance: The center of gravity was significantly aft of the allowable limit.
- Pilot judgment: The pilot failed to properly evaluate the risks of operating outside the weight and balance envelope.
- Human factors: The pilot experienced fatigue and exhibited a pattern of disregarding safety procedures, including the habitual failure to use seatbelts.
- Operational non-compliance: The aircraft was operating with an expired airworthiness certificate and outdated maintenance logs.