What happened
On November 28, 2008, a Beechcraft BE58, registered as N400SA, was performing a local flight at Anápolis Aerodrome (SWNS) in Brazil. The aircraft, which was in the process of being transferred to Brazil and had recently lost its US registration, was carrying six occupants. After completing a low pass alongside runway 25, the pilot attempted to execute a *tonneau* (a type of aerobatic roll). During the maneuver, the aircraft failed to gain sufficient altitude and struck the ground approximately 1,200 meters from the threshold of runway 25. The impact caused the aircraft to slide along the runway, eventually coming to a stop past runway 07, where it caught fire and exploded. The accident resulted in four fatalities and two serious injuries.
The investigation
CENIPA's investigation established that the aircraft was in an unairworthy condition. A previous technical inspection by ANAC had deemed the aircraft unairworthy because the engine overhaul intervals (TBO) had expired, and the owner had not provided documentation to verify necessary corrections. Furthermore, the pilot was qualified to operate the aircraft but was not rated or authorized to perform aerobatic maneuvers. The investigation also noted that the aircraft was not certified for aerobatic flight. GPS data confirmed the aircraft reached a speed of 359 km/h during the approach to the maneuver. The investigation highlighted a significant lack of regulatory compliance, as the aircraft was being operated without a valid airworthiness certificate and without a flight plan.
Findings
- The primary cause of the accident was the execution of an unauthorized aerobatic maneuver by a pilot not qualified for such maneuvers in an aircraft not certified for aerobatics.
- The pilot exhibited excessive confidence and poor judgment, likely influenced by the presence of passengers and onlookers.
- The operator's organizational culture was deficient, characterized by a pattern of non-compliance with safety regulations and a complacent attitude toward operating unairworthy equipment.
- The pilot's improper application of controls during the *tonneau* prevented the aircraft from maintaining enough altitude to clear the terrain.
- The aircraft was operating in an unairworthy state due to expired engine maintenance intervals.