What happened
On October 8, 2018, at approximately 19:50 UTC, a Twin Commander 500-S, registration PT-ICR, operated by Camejo Táxi Aéreo Ltda., arrived at Lauro Kurtz Airport (SBPF) in Passo Fundo, RS, following a flight from Porto Alegre (SBPA). The aircraft was performing a cargo transport mission with two pilots and two passengers on board.
After the aircraft had landed and reached the parking apron, the crew began the engine shutdown procedure. During this process, the pilot inadvertently moved the landing gear lever, causing a partial retraction of the landing gear. The aircraft sustained light damage during the incident, but all four occupants escaped without injury.
The investigation
CENIPA's investigation established that the pilots held valid medical certificates and appropriate multi-engine instrument ratings, with significant experience on the aircraft type. The aircraft was airworthy, within weight and balance limits, and all maintenance records were up to date. Meteorological conditions were favorable for the flight.
The investigation revealed that the crew had undergone an ANAC proficiency check earlier that same morning, a process that had caused significant tension. Although the pilot was not originally scheduled to fly the afternoon leg, he assumed the mission to avoid canceling a scheduled contract with a security transport company. The investigation noted that the pilot also held administrative and ownership roles within the company, which contributed to a high workload.
During the shutdown, the pilot performed an unplanned and thoughtless action of unlocking and retracting the gear instead of cutting the engines. This error was facilitated by the physical proximity of the landing gear lever and the fuel cutoff controls. Simultaneously, the co-pilot was distracted by recording the landing time and failed to monitor the procedure.
Findings
- Loss of attention: The pilot's focus decreased during the post-landing phase, leading to the erroneous movement of the gear lever.
- Lack of monitoring: The co-pilot was preoccupied with administrative tasks (noting the landing time) and failed to supervise the shutdown procedure.
- Management supervision: The company's management failed to properly oversee operational activities, allowing the same crew to fly a second mission on the same day following a high-stress proficiency check.
- Work organization: The pilot's accumulation of operational and administrative duties created psychological pressure to complete the flight schedule.