What happened
On 16 July 2013, a Raytheon BE58, registration PR-OKK, was performing a transport flight from Eduardo Gomes Aerodrome (SBEG) to Flores Aerodrome (SWYN). During the takeoff roll, the aircraft unexpectedly veered to the left, exiting the runway at an angle of approximately 30 degrees from the centerline.
The aircraft traveled roughly 690 meters from the point of deviation before colliding with trees and a steep terrain depression near taxiway Alpha. The impact caused the right engine propeller to detach and the aircraft to pitch downward into a 10-meter deep depression. A massive post-impact fire ensued, fueled by the aircraft's remaining fuel, destroying the airframe. The pilot and two passengers died at the scene, while three additional passengers succumbed to severe burns in the hospital days later.
The investigation
CENIPA's investigation focused on several critical factors, including the aircraft's weight, engine performance, and environmental conditions. Investigators noted that the aircraft was operating with an excess weight of approximately 114.6 kg above its maximum takeoff weight.
Analysis of the wreckage suggested a possible failure of the left engine, which would have created a significant yawing tendency. The investigation also examined the timing of the departure, which occurred only 75 seconds after the landing of a much larger Airbus A320. While the separation met standard regulations, the investigation considered the potential for lingering wake turbulence from the heavy aircraft to have affected the BE58's stability. Furthermore, the investigation looked into the pilot's recent personal and professional stressors, which may have impacted his ability to manage the emergency.
Findings
- Excessive takeoff weight: The aircraft was loaded 114.6 kg above its maximum allowable takeoff weight.
- Engine failure: Evidence indicated a possible loss of power in the left engine, which was not immediately corrected by the pilot.
- Wake turbulence: The proximity to the landing of a medium-sized aircraft may have contributed to the loss of directional control.
- Pilot performance: The pilot failed to implement corrective actions, such as applying rudder or braking, to maintain the runway centerline or abort the takeoff.
- Organizational factors: A lack of systematic crew monitoring within the operator's organization meant that the pilot's diminished focus due to personal and professional stressors went unaddressed.