What happened
On October 28, 2004, a Cessna 172, registration PT-AYR, departed from Amarais Aerodrome in Campinas, São Paulo, bound for Cuiabá, Mato Grosso. The flight was intended as a transport mission with one pilot and two passengers on board. Shortly after takeoff, the aircraft struggled to gain sufficient airspeed and altitude. The pilot attempted an emergency landing in an open field adjacent to the runway. During the landing maneuver, the right wing struck the ground, causing the aircraft to capsize. The impact resulted in substantial damage to the aircraft and caused serious injuries to all three occupants.
The investigation
The investigation examined the aircraft's mechanical condition, maintenance records, and the circumstances of the takeoff. While the engine was found to be operational and producing appropriate power, investigators discovered that the aircraft's Airworthiness Certificate was suspended due to an expired annual maintenance inspection. Furthermore, the maintenance logs for the airframe, engine, and propeller were outdated, and fuel records were inconsistent.
Witnesses observed that the aircraft utilized nearly the entire runway length before being rotated at an abrupt, high pitch angle, which resulted in a very low rate of climb. Although investigators considered fuel contamination as a possibility, this was ruled out because the engine RPM decreased uniformly without the intermittent sputtering characteristic of water in fuel. Instead, the investigation determined that the drop in RPM was a result of increased propeller load due to the high angle of attack and decreasing airspeed.
Findings
- Overweight takeoff: The aircraft was fully fueled and operating above the maximum takeoff weight for the specific altitude and temperature conditions.
- Improper flight planning: The loading and fueling process failed to account for the aircraft's performance limitations and runway characteristics.
- Flight indiscipline: Failure to adhere to established procedures and established flight safety protocols.
- Flawed decision-making: Inadequate decision-making processes regarding the takeoff configuration.
- Maintenance and oversight issues: The aircraft was operating with a suspended airworthiness certificate, outdated maintenance logs, and inadequate managerial supervision.