What happened
On August 24, 2006, a Cessna 210N, registration PT-OUY, was performing touch-and-go training maneuvers at the Borba Aerodrome (SWBR) in Amazonas, Brazil. The flight originated from Manaus (SWFN) with a pilot and one passenger on board. During the fourth go-around attempt, the aircraft drifted left of the runway centerline, struck a fence, and impacted the ground. The impact caused the engine to detach, rupturing fuel lines and electrical wiring, which triggered a significant post-impact fire that destroyed the aircraft.
The pilot sustained serious injuries, while the passenger suffered minor injuries. The aircraft was a total loss.
The investigation
CENIPA investigators established that the pilot was intentionally conducting training with a tailwind to gain experience in challenging conditions. The pilot, who held a private pilot license but had only approximately 220 total flight hours and 60 hours in the Cessna 210N, was operating the aircraft as a legal custodian following its seizure by the Federal Police.
While the pilot suggested a potential propeller governor failure, investigators could not confirm this, as the passenger reported no engine malfunctions or unusual noises prior to the accident. The investigation focused on the flight dynamics during the go-around, noting that the pilot's actions—specifically pulling the control column backward and retracting flaps in a manner inconsistent with the recommended checklist—contributed to a loss of airspeed and lift.
Findings
- The aircraft entered a stall due to insufficient airflow over the wings, exacerbated by the tailwind component and the pilot's maneuvers during the turn.
- The pilot's lack of flight experience and insufficient time in the specific aircraft model significantly impacted the safe execution of the maneuver.
- The decision to perform training maneuvers with a tailwind was deemed technically inadvisable and demonstrated poor judgment.
- The pilot failed to wear a seatbelt during the operation.
- There was a lack of technical or operational flight safety supervision, as the Federal Police lacked a formal training manual or flight safety doctrine for their operations.
- The aircraft was within weight and balance limits at the time of the accident.