What happened
On June 29, 2010, a Beechcraft BE30, registration PP-EPD, was performing a test flight following scheduled maintenance at the Jundiaí Aerodrome (SBJD) in São Paulo. The flight was intended to be a short trip to Sorocaba. The flight crew, consisting of two pilots, had also taken four technicians on board, bringing the total number of occupants to seven.
During the second takeoff attempt, the aircraft experienced a simultaneous loss of power in both engines immediately after rotation. The pilot in command managed to advance the throttles and partially restore power to the right engine. After declaring an emergency and completing an emergency traffic pattern, the crew attempted to land. During the landing roll, the pilot applied reverse thrust on the functioning right engine while the aircraft was at a low speed. This caused the aircraft to yaw significantly to the right. Due to insufficient rudder effectiveness at low speed, the pilot lost control, and the aircraft exited the runway to the right, coming to a stop on a grassy area. The aircraft sustained substantial damage to both engines and the right propeller, and two sets of runway and taxiway lighting were destroyed. All seven occupants escaped without injury.
The investigation
CENIPA investigators examined the engines through static and borescope tests, as well as dynamic testing. These investigations, supported by engine manufacturers, found no internal abnormalities or operational parameters that would explain the initial loss of power; therefore, the cause of the engine failure remained undetermined. \nThe investigation also scrutinized the operational preparations. It was discovered that the pilots had added four extra passengers without recalculating the critical takeoff speeds (V1, V2, and VR), simply adding a 5-knot margin to previous calculations. Furthermore, the investigation found that the crew lacked a defined flight profile for the test mission and had not performed recent flight simulator training, which contributed to difficulties in managing the emergency and maintaining coordination in the cockpit.
Findings
- Improper use of reverse thrust on the single operational engine at low speed caused the uncontrolled yaw and subsequent runway excursion.
- Failure to recalculate takeoff speeds after increasing the aircraft's weight due to additional passengers.
- Lack of cockpit coordination and failure to follow established emergency checklists following the engine power loss.
- Inadequate flight planning, as the crew lacked a standardized procedure or roadmap for the maintenance test flight.
- Deficiencies in management oversight, specifically regarding the monitoring of crew training and the lack of simulator training for the pilots.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to ensure that the aircraft operator maintains adequate supervision over outsourced flight crews, particularly regarding training standards. Additionally, a recommendation was made to study the feasibility of legislation ensuring periodic training for crews operating aircraft under direct public administration.