What happened
On February 28, 2012, a Cessna 208B, registration PT-PTB, operated by Clayton TáxiAéreo Ltda, was performing a ferry flight from Flores Aerodrome (SWFN) to Eduardo Gomes (SBEG) in Manaus, Brazil. The flight was intended to reposition the aircraft for a scheduled charter service.
During the takeoff roll, the aircraft experienced pitch control issues and failed to gain sufficient altitude. Shortly after passing the end of runway 11, the aircraft struck a public lighting pole and high-voltage power lines. The impact with the lines caused the left landing gear to be severed and triggered a 180-degree wing roll, leaving the aircraft in an inverted position. The aircraft subsequently struck trees, resulting in the separation of the tail and the right wing, before impacting the ground. The pilot sustained fatal injuries at the scene, and the aircraft suffered substantial damage.
The investigation
CENIPA's investigation focused on the sequence of events leading to the loss of control. Investigators examined the aircraft's maintenance history, which showed a recent "Mini Check" and "Phase 4" revision completed only ten hours prior to the accident. The investigation also scrutinized the pilot's performance and the operator's organizational culture.
A critical finding was the presence of an uncertified, non-homologated control lock in the cockpit. Unlike standard, highly visible locks, this device was small, red, and positioned behind the control column, making it difficult for the pilot to notice. Investigators also found that the pilot was performing several pre-flight duties alone and in haste to meet a subsequent flight schedule, which contributed to the oversight.
Findings
- The pilot failed to remove the control lock from the flight controls during the pre-flight inspection and taxi.
- The unremoved control lock prevented the necessary pitch control required for takeoff.
- The control lock used was an uncertified, non-homologated part that was poorly visible to the pilot.
- The pilot was operating under time pressure to complete a refueling stop and maintain the schedule for a subsequent charter.
- The operator's organizational culture allowed for the use of non-standard equipment and lacked standardized procedures for maintenance personnel assisting in pre-flight checks.
- The pilot's checklist was not strictly followed due to a combination of haste and overconfidence in managing multiple tasks solo.