What happened
On November 21, 2004, at approximately 17:3/UTC, an EMB-712 aircraft, registration PT-RKC, departed from the Ely Rego Aerodrome in Balsa Nova, Paraná, for a local flight under visual flight rules (VFR). The aircraft was carrying one pilot and four passengers. Shortly after takeoff, the aircraft struck the treetops of a wooded hill before impacting the ground in a steep, nose-down attitude.
The impact resulted in two fatalities (the pilot and one passenger) and several injuries, including one passenger with serious injuries and two with minor injuries. The aircraft sustained substantial structural damage to the fuselage, wings, and empennage, and the engine was severely damaged upon ground impact.
The investigation
CENIPA's investigation focused on the aircraft's performance and the pilot's operational decisions. The investigation established that the aircraft was operating near its maximum takeoff weight and was flying on a grass runway that featured an uphill slope.
Investigators analyzed the flight dynamics and concluded that the pilot likely deployed full flaps during the rotation phase. While this allowed the aircraft to leave the ground, the configuration likely degraded performance during the second segment of the climb, preventing the aircraft from gaining sufficient altitude. The investigation also noted that the pilot's previous experience was primarily in ultralight aircraft, and he had not been specifically trained for high-load operations on unpaved, uphill runways in this specific aircraft type.
Findings
- The pilot's excessive self-confidence and a sense of invulnerability influenced his decision-making.
- The pilot failed to perceive critical operational risks, such as the combination of a grass runway, an uphill gradient, and high aircraft weight.
- The use of full flaps during takeoff contributed to a loss of climb performance.
- The pilot's training and experience were insufficient for operating this aircraft type near its performance limits.
- The pilot's previous flight training did not adequately cover operations involving maximum load or restricted runway conditions.