What happened
On April 21, 2022, at approximately 20:00 UTC, a Cessna 208B EX, registration PR-SLT, was performing a passenger transport flight from Aeródromo Paa-Piu (SWMV) to Aeródromo Pouso da Águia (SWPD) in Roraima, Brazil. The aircraft was operated by Voare Táxi Aéreo Ltda. and was carrying two crew members and nine passengers.
During the takeoff roll on the 850-meter grass runway, the pilot applied power while the aircraft was still in a right-hand turn entering the runway. Shortly after applying power, the aircraft drifted to the left side of the runway and entered dense vegetation. The impact caused light damage to the propeller, engine, and the left wing leading edge, but all eleven people on board escaped without injury.
The investigation
CENIPA's investigation focused on the flight crew's performance and the operational environment. The investigation established that the pilot in command (PIC) was relatively new to the company, having completed practical training only 20 days prior. While highly experienced in the standard C208B model, the PIC lacked experience with the more powerful C208B EX variant and had very limited experience operating in that specific region.
The investigation found that the takeoff procedure was improvised. The pilot intended to perform a "no-stop takeoff," a procedure not authorized by the operator's General Operations Manual. Furthermore, the second in command (SIC) reported that the takeoff roll began before the completion of the required checklists. The investigation also noted that the crew's communication was not assertive, as the SIC did not alert the PIC to the incomplete checklist or the improper maneuvering.
Findings
- The pilot initiated the takeoff roll while the aircraft was still executing a turn, which likely subjected the aircraft to significant torque effect and spiraling slipstream forces.
- Incomplete checklist execution regarding brakes, power lever setting, and annunciator checks.
- Lack of experience by both crew members regarding the specific aircraft variant (C208B EX) and the local operational environment.
- Poor crew resource management (CRM), characterized by ineffective communication and a lack of assertive intervention by the SIC.
- Organizational failure by the operator to identify the risk of assigning a crew with low experience in the specific equipment and environment to the same flight.