Accident Details
A single-engine airplane departed Boituva Aerodrome for a local skydiving flight carrying 15 skydivers and a pilot. Shortly after takeoff, while climbing, the pilot encountered engine problems and attempted an emergency landing in an open field. The airplane successively impacted an embankment and a fence before coming to rest upside down in a grassy area. Two passengers were killed, nine were injured, and five escaped unhurt. The airplane was damaged beyond repair.
Investigation Findings
The official investigation identified several contributing factors to the accident. Under the category of training, the frequent and improper use of the Emergency Power Lever (EPL) during emergency landing training throughout the aircraft's operation may have contributed to engine degradation. Under work-group culture, the recurring improper use of the EPL by multiple pilots during the operation of the aircraft may have contributed to engine degradation. Regarding handling of aircraft flight controls, it is possible that the pilot's use of the aircraft's EPL was inappropriate and contributed to the severity of the accident. In aircraft maintenance, the large number of seat belts that detached due to the shearing of their floor attachment brackets and their corroded condition indicated that maintenance actions were not effective in ensuring the integrity and reliability of these materials, which contributed to the injuries sustained by the parachutists during the emergency landing. Under managerial oversight, the oversight of operational procedures related to the use of the EPL was not effective in identifying the risks associated with its use in disagreement with the aircraft manufacturer's specifications.