What happened
On July 29, 2018, a Hawker Beechcraft C90GTI, registration PP-SZN, was performing a flight from Videira, Santa Catarina, to São Paulo. During the approach to Campo de Marte Aerodrome (SBMT), the pilot encountered a malfunction regarding the landing gear position indicator lights, specifically noting that the left main landing gear strut did not appear to be properly indicated as locked.
In an attempt to verify the gear status and ensure safety, the pilot performed a series of maneuvers, including low passes and go-arounds. During the process, the pilot utilized the emergency gear extension system, with passengers even assisting in the manual procedure due to the pilot's physical fatigue. After several attempts and receiving verbal assistance from another King Air crew on the frequency, the pilot decided to perform a touch-and-go procedure. However, during the fourth approach, after crossing the runway threshold, the aircraft rolled around its longitudinal axis, lost control, and struck the ground. The impact and subsequent fire caused substantial damage to the aircraft. The pilot sustained fatal injuries, while two passengers suffered serious injuries and four others sustained minor injuries.
The investigation
CENIPA's investigation focused on the sequence of events following the landing gear indication failure. Investigators examined the aircraft's maintenance records, noting that while the airworthiness certificate was valid, the logbook records for the airframe, engine, and propeller were out of date. The investigation also reviewed the pilot's experience, noting he was highly experienced in multi-engine aircraft but lacked recent simulator training for this specific glass-cockpit model. Analysis of the wreckage and flight data confirmed that the aircraft was within weight and balance limits and that no mechanical failures were found that would have compromised controllability, other than the gear indication issue.
Findings
- The pilot's decision-making process was compromised by a fixation on resolving the landing gear indication failure, which led to an inadequate assessment of the situation.
- The pilot likely experienced "tunnel vision," focusing so intently on the gear lights that other critical flight procedures were neglected.
- The final approach was conducted at a speed dangerously close to the stall speed.
- It is possible that a sudden increase in engine power to prevent a stall created enough torque and P-factor to induce a left roll and subsequent spin.
- The pilot's lack of recent simulator training may have hindered his ability to manage the high workload and emergency procedures effectively.