What happened
On November 6, 2015, a Piper PA-46-350P, registration PR-VDA, was performing a cargo transport flight from Flores, Amazonas, to Tefé, Amazonas. The aircraft, operated by Cleiton Táxi Aéreo Ltda., was carrying two pilots and two passengers.
Upon landing at Tefé Aerodrome (SBTF), the aircraft's nose gear made contact with the runway, at which point the aircraft began to veer toward the right. In an attempt to maintain the runway centerline, the pilot applied rudder corrections. However, these inputs caused the aircraft to oscillate across the centerline, eventually resulting in a lateral skid. Realizing the aircraft could not be kept within the runway limits, the pilot shut down the engine. The aircraft exited the runway via the right side, traveling 1 and 180 meters into a grassy area before coming to a stop. All four occupants escaped the incident uninjured, though the aircraft sustained light damage.
The investigation
CENIPA investigators examined the aircraft's maintenance history and the pilot's actions. The investigation noted that the aircraft had undergone a significant modification (STC) to replace its conventional engine with a turbine engine. This modification changed the required tire pressure from 50 PSI to 47 PSI.
Investigators also reviewed historical data regarding the PA-46 family, noting that the directional steering system has a known history of failures that can lead to loss of control on the ground. While the crew reported a "heavy pedal" sensation prior to the event, a subsequent inspection of the aircraft found no mechanical discrepancies in the steering system or landing gear adjustments. However, the investigation found that the operator's maintenance management structure was irregular, as the person identified as the Maintenance Director held incompatible professional commitments that prevented them from properly overseeing maintenance operations.
Findings
- The pilot's rudder inputs may have contributed to the loss of control through an error reversal, where excessive correction caused the aircraft to drift further from the centerline.
- There was an indeterminate possibility of a mechanical failure in the directional control system.
- The operator's maintenance oversight was compromised due to administrative irregularities regarding the responsibilities of the Maintenance Director.