What happened
On May 20, 2018, a Cessna 560XL, registration PR-AAA, was performing a takeoff from Aeródromo Francisco de Assis (SBJF) in Juiz de Fora, Brazil. The flight was intended for private transport to Belém, carrying two pilots and seven passengers. During the takeoff roll, the crew attempted an aborted takeoff procedure. However, the aircraft failed to respond as expected during the rotation attempt and continued along the runway, eventually overrunning the far end of the pavement. The aircraft sustained light damage to the forward lower fuselage and landing gear, but all nine occupants escaped without injury.
The investigation
CENIPA's investigation established that the aircraft was operating above its maximum takeoff weight. While the initial flight plan accounted for four passengers, three additional passengers were added during boarding without prior coordination with the flight crew. Consequently, the pilots did not update the performance data in the Flight Management System (FMS). The investigation also noted that a "NO TAKEOFF" warning light had illuminated on the panel during the takeoff roll, indicating a configuration discrepancy. The crew decided to proceed with the takeoff despite this warning. The investigation further examined the crew's decision-making process, noting that the decision to abort the takeoff was made too late, after the aircraft had already reached a high speed.
Findings
- The aircraft was overweight by 175 kg due to the uncoordinated addition of three passengers.
- Failure to update flight performance data in the FMS following the change in passenger count.
- The crew's decision to proceed with the takeoff despite the illumination of the "NO TAKEOFF" warning light.
- A lack of communication between the operator and the crew regarding changes to the passenger manifest.
- Inadequate cockpit coordination and a lack of defined emergency procedures during the pre-flight briefing.
- Potential complacency caused by a previous experience with the same warning light on the preceding day.