What happened
On April 15, 2022, a Raytheon Aircraft C90GTI, registration PR-ARO, was conducting a private passenger flight from Marabá, PA, to Porto Seguro, BA. During the cruise phase, the crew observed low oil pressure in the right engine and identified an oil leak from the engine cowling. The crew decided to perform a precautionary landing at Ibotirama Airport (SNIT) in Bahia.
During the approach, the crew transitioned from the intended runway 16 to runway 34. The aircraft touched down approximately 600 meters from the threshold of runway 34. During the landing roll, the left main tire burst, likely due to excessive braking. The aircraft subsequently exited the runway at the opposite end, coming to a stop 80 meters beyond the runway limits. All 8 people on board (two crew members and six passengers) were uninjured, though the aircraft sustained light damage.
The investigation
CENIPA investigators analyzed the Cockpit Voice Recorder (CVR), which revealed that the crew's initial claim—that the landing was due to a passenger's medical issue—was inaccurate. The CVR confirmed the engine oil pressure drop was the actual cause. The investigation also noted that the crew did not utilize the aircraft's checklist during the emergency.
Investigators examined the landing parameters and determined that while the aircraft touched down further down the runway than ideal, a full stop within the runway limits was still possible. The investigation focused on the crew's decision-making, the use of flight controls, and the coordination between the pilot flying (PF) and the pilot monitoring (PM) during the engine shutdown and subsequent approach.
Findings
- Improper task management: The crew implemented an improvised division of duties where the PM controlled the power lever of the operating engine under the direction of the PF, a procedure not defined in the aircraft's operating manual.
- Poor cockpit coordination: The decision-making process was compromised by a lack of standardized coordination between the two pilots during the emergency.
- Inadequate approach parameters: The aircraft crossed the runway threshold at an excessive height and approach speed, likely due to delayed visual identification and the complex maneuvering used during the approach.
- Failure to use available resources: The crew did not utilize reverse thrust, which could have helped reduce the landing distance.
- Improper braking: Excessive application of the brakes contributed to the failure of the left main tire.