What happened
On December 31, 2016, at approximately 19:40 UTC, a Cessna 188B, registration PP-LJM, was performing a ferry flight between two unpaved landing strips in Uruguaiana, Rio Grande do Sul. The aircraft, operated by Malek Pulverizações Aéreas Ltda, landed at the Rota do Sol farm following a flight from a nearby strip used by the operator.
Upon completing the landing, the pilot observed support vehicles positioned near the runway threshold. To avoid a collision with these vehicles, the pilot executed a 180-degree turn on the grass surface. During this maneuver, the aircraft's tail gear locked and subsequently broke, leading to the deformation of the tail cone. The aircraft sustained substantial damage, though the pilot remained uninjured.
The investigation
The CENIPA investigation focused on the operational environment and the decision-making process leading to the maneuver. Investigators found that the pilot also served as the owner and sole administrator of the company, meaning there was no independent person responsible for flight planning or management supervision.
It was established that the pilot had relied on information from a local administrator, who lacked aviation experience, stating that the runway was not wet despite recent rainfall. The investigation confirmed that the grass runway was, in fact, wet at the time of the incident. Additionally, while the aircraft was within weight limits, investigators noted that the center of gravity was positioned beyond the rear limit, though they could not definitively link this to the gear failure.
Findings
- Organizational flaws: The centralization of all management, planning, and operational tasks in a single individual led to a lack of oversight.
- Inadequate flight planning: The absence of organizational control processes contributed to poor planning, specifically regarding the assessment of runway conditions.
- Management failures: Ineffective managerial supervision and a lack of established organizational processes for monitoring aerial activities.