What happened
On March 2, 2011, a Beechcraft A-36, registration PT-OIS, was performing a repositioning flight from Bacacheri Airport (SBBI) to Pará de Minas (SNPA) for a scheduled annual maintenance inspection. During the takeoff roll on runway 18, the aircraft utilized the entire available runway length but failed to rotate. The aircraft continued down the runway, crossed the opposite threshold, overflew two residential buildings, and ultimately struck the roof of a third house. The impact occurred at high power, and a subsequent fire destroyed the aircraft. The pilot sustained fatal injuries at the scene.
The investigation
CENIPA investigators examined the wreckage and the aircraft's mechanical systems. An inspection of the engine revealed no failures in the fuel or ignition systems, and the crankshaft showed no signs of abnormal wear. The investigation confirmed the aircraft was within its specified weight and center of gravity limits. Video analysis of the runway showed the aircraft drifting slowly toward the center of the runway with no visible movement of the flight control surfaces during the final portion of the roll.
Investigators also considered the pilot's medical history. Although the pilot was physically active and had low cardiovascular risk according to recent ergometric tests, his age and gender were noted as risk factors for sudden medical events. While no specific medical cause could be definitively proven, the lack of any reduction in engine power or use of brakes suggested the pilot may have been unable to react to the situation.
Findings
- Unconsciousness of undetermined cause was the primary human factor, with the possibility of a sudden medical event, such as a stroke, contributing to the loss of aircraft control.
- The aircraft was operating within all weight and balance limitations.
- The engine and mechanical systems were functioning normally prior to the impact.