What happened
On April 27, 2020, a Cessna 182 (registration PT-OBU) was attempting a takeoff from Flores Aerodrome (SWFN) in Manaus, Brazil, destined for Rurópolis, Pará. The aircraft was carrying a pilot and five passengers. During the takeoff roll on runway 11, the aircraft traveled approximately 700 meters without lifting off. The plane veered off the right side of the runway, crossed an embankment, passed through local vegetation, and ultimately collided with a masonry wall. The impact resulted in substantial damage to the aircraft. The pilot sustained serious injuries, two passengers suffered minor injuries, and three passengers were uninjured.
The investigation
CENIPA's investigation revealed that the pilot had not performed a full preflight inspection, only adding engine oil before the flight. Crucially, the investigation found that the aircraft's standard control lock—which includes a warning tag—had been replaced by an uncertified wire. This wire was physically blocking the movement of the control column. Because the pilot failed to perform the 'Flight Controls - FREE and CORRECT' check during the takeoff phase, the restriction went unnoticed.
Furthermore, the investigation noted several regulatory and operational discrepancies. The aircraft was operating outside of its approved weight and balance limits by approximately 30 kg. The passenger configuration was also improper; the aircraft was carrying six people in a configuration not authorized by the manufacturer's loading arrangements, and one child was being transported in a seat without a seatbelt. Additionally, the investigation noted that passenger boarding had occurred at an unauthorized location near a hangar, rather than the designated administrative area.
Findings
- The unauthorized wire used as a makeshift control lock prevented the pilot from rotating the aircraft.
- The pilot failed to utilize the aircraft checklist, specifically the flight controls check, prior to takeoff.
- The aircraft was operating beyond its maximum weight and balance limits.
- The passenger seating arrangement violated both the manufacturer's loading instructions and Brazilian civil aviation regulations (RBAC 91).
- Maintenance records for the airframe, engine, and propeller were outdated.
- The pilot's lack of familiarity with this specific aircraft (his first flight in PT-OBU) contributed to the failure to identify the improvised lock.