What happened
On April 13, 2019, a Socata ST-10, registration PT-DME, took off from Carlos Prates Aerodrome (SBPR) in Belo Horizonte, Brazil, to perform a local test flight following maintenance. Shortly after departure, the pilot declared an emergency and requested to return to the airport. Seconds later, the aircraft crashed into a residential area located on the extension of runway 09.
The impact destroyed the aircraft and caused a fire that partially consumed the wreckage. The crash also damaged local infrastructure, including the power grid, walls, and roofs of nearby houses. The pilot sustained fatal injuries at the scene.
The investigation
CENIPA investigators established that the aircraft experienced an in-flight engine failure. Evidence from the site indicated that the engine was not developing power at the moment of impact. The investigation revealed that the aircraft's airworthiness certificate had expired in January 2019, and the engine, airframe, and propeller logbook records were outdated.
Investigators also found that the aircraft had been released for a test flight under a special authorization (AEV) to perform maintenance inspections that were not within the standard scope of the maintenance organization's authorization. Furthermore, reports indicated that the pilot had not performed the required engine checks prior to takeoff and frequently relied on memory checks rather than formal procedures.
Findings
- Engine Failure: The primary cause of the accident was an engine failure during flight.
- Maintenance and Oversight: Inadequate supervision by the maintenance organization and the release of the aircraft without updated primary records in the logbooks contributed to the unsafe condition.
- Pilot Performance: The pilot's failure to perform pre-takeoff engine checks and a tendency toward non-observance of procedures were noted. The investigation also suggested that an emotional state of anxiety or fear may have impaired the pilot's ability to manage the emergency.
- Flight Control: The high-angle, perpendicular trajectory of the impact suggested an uncontrolled approach during the attempt at a forced landing.
Safety action
CENIPA issued recommendations to Brazil’s National Civil Aviation Agency (ANAC) to:
- Ensure the maintenance organization improves its quality control and management supervision regarding the approval of aircraft for return to service.
- Review and strengthen the criteria used for granting special authorizations for maintenance tasks not included in an organization's standard scope of work.