What happened
On September 16, 2019, a Cessna 208B, registration PT-MHC, operated by Two Air Taxi Ltd., departed Eduardo Gomes Aerodrome (SBEG) in Manaus, Brazil, bound for Maués. The flight was scheduled to transport cargo and eight passengers along with two crewmembers.
Shortly after departing from runway threshold 29, the aircraft encountered severe meteorological conditions. The aircraft lost altitude and impacted a wooded area approximately 600 meters from threshold 11. The impact resulted in substantial damage to the airframe, including the fuselage, wings, and landing gear. The accident resulted in six serious injuries and four minor injuries among the crew and passengers, with no fatalities reported.
The investigation
CENIPA's investigation focused on the meteorological environment and the decision-making process leading to the takeoff. Satellite imagery confirmed that a significant storm system, characterized by intense cumulonimbus clouds and very low cloud-top temperatures, was moving directly over the Manaus region at the time of the accident.
Investigators examined the flight planning and operational pressures, noting that a NOTAM had scheduled the closure of the Manaus runway for maintenance later that night. This created a narrow window for operations, which influenced the crew's timeline. The investigation also reviewed the crew's performance, the role of the air traffic controller in providing weather updates, and the company's operational culture regarding weather limits.
Findings
- Adverse meteorological conditions were a primary contributor, as the aircraft encountered severe turbulence and strong descending winds, likely involving windshear, which prevented the aircraft from maintaining a positive climb rate.
- The pilot in command made a wrong assessment of the meteorological conditions, choosing to proceed with takeoff despite heavy rain and developing storms.
- Operational pressure was a significant factor; the pilot felt pressured to complete the flight before the scheduled runway closure, leading to a decision that bypassed established safety margins.
- Flight planning was inadequate, as the schedule left no margin for weather-related delays, increasing cockpit workload and stress.
- There was a lack of assertive Crew Resource Management (CRM), as the second in command did not alert the pilot in command to the unfavorable conditions.
- The air traffic tower did not inform the crew of significant recent changes in the local weather conditions prior to departure.