What happened
On June 16, 2007, a PA-34-200 aircraft, registration PT-KGK, was performing a local flight for touch-and-go instruction at Jacarepaguá Aerodrome (SBJR) in Rio de Janeiro. During the landing roll, the aircraft experienced a failure in the right brake system. Unable to stop within the remaining runway length, the instructor took control and intentionally steered the aircraft off the left side of the runway. The pilot's intent was to avoid the runway end, where lighting pylons were located, believing the aircraft could safely decelerate on the grass. However, the right landing gear struck a concrete box located 21 meters from the runway edge. The impact caused severe damage to the right landing gear, right wing, right propeller, and minor damage to the right engine. The two crew members on board were uninjured.
The investigation
CENIPA's investigation revealed significant maintenance and organizational failures. Although mechanics reported that the brake pads had been replaced, there was no official maintenance record to confirm this. Furthermore, the inspection of the brake assemblies showed that the friction surfaces were highly porous and one pad had a small crack. The investigation also found that the required conditioning procedure for the new brake pads had not been performed because the maintenance staff did not follow the manufacturer's instructions. Additionally, the investigation noted that the maintenance logs lacked proper signatures from the executors and inspectors, and there was a lack of communication between the maintenance and operations departments, with many discrepancies being reported only verbally rather than in the aircraft logbook.
Findings
- Inadequate maintenance execution: The maintenance service failed to perform the brake pad conditioning procedure specified by the manufacturer.
- Improper pilot decision-making: The instructor's decision to steer off the runway with the engines running, rather than utilizing the available stopway, contributed to the impact.
- Organizational culture: A widespread practice existed within the flying club where pilots were encouraged to minimize brake use, which contradicted manufacturer recommendations and led to the degradation of the brake pad surfaces.
- Language barriers: Maintenance personnel lacked the English proficiency necessary to understand and implement procedures described in English-language manufacturer manuals.
- Airport infrastructure: The presence of non-frangible obstacles, specifically the concrete box within the runway strip, aggravated the consequences of the excursion.
- Training deficiencies: There was a lack of specific training regarding emergency procedures such as short/long landings and runway excursions.