What happened
On September 5, 2021, at approximately 19:00 UTC, a Cessna U206F, registration PT-KAG, was performing a scheduled ferry flight from Uraricoera Aerodrome (SJNC) to Aeródromo de Pouso da Águia (SWPD) in the state of Roraima, Brazil. The aircraft, operated by Voare Táxi Aéreo Ltda., was beginning its takeoff roll on Runway 07.
After traveling roughly 100 meters down the runway, the pilot's seat unexpectedly slid backward along its tracks. This movement left the pilot unable to reach the rudder pedals, resulting in a loss of directional control. The aircraft veered to the left, crossed the runway boundary, and struck low-lying vegetation, causing the aircraft to overturn. The aircraft sustained substantial damage, but the pilot escaped the wreckage uninjured.
The investigation
CENIPA investigators established that while the pilot was properly licensed and the aircraft was airworthy and within weight limits, a critical safety device was missing. Documentation indicated that a "Secondary Seat Stop" (part of Service Bulletin SEB0SB-5) had been installed on PT-KAG in May 2021; however, this device was not present at the time of the accident, and there was no maintenance record explaining its removal.
The investigation also noted that the aircraft was operating on a short runway where the full length could not be utilized because another aircraft was parked near the threshold. During the excursion, the pilot attempted to extend the flaps to the 40-degree position in an effort to gain lift and avoid the vegetation, a practice the investigation identified as an informal local technique that actually increases drag and alters aircraft attitude.
Furthermore, the investigation found that the operator's Standard Operating Procedures (SOP) and the Pilot's Operating Handbook (POH) lacked standardized procedures for an aborted takeoff. The SOP only provided instructions for braking but failed to address reducing engine power, and the pre-flight checklists did not include a specific verification for the seat stop device.
Findings
- The absence of the Secondary Seat Stop device, which would have prevented the seat from sliding backward.
- The uncontrolled rearward movement of the pilot's seat, which rendered the flight controls (pedals) inaccessible to the pilot.
- Inadequate risk management regarding the use of a limited runway length due to parked aircraft.
- Lack of standardized procedures for aborted takeoffs in the company's SOP and the aircraft's POH.
- The use of an unapproved takeoff technique (extending flaps to 40 degrees) which increased drag during a critical phase of flight.