What happened
On November 27, 2018, at approximately 16:30 UTC, a Beechcraft 58, registration PR-SAC, was performing a local flight at the Cruzeiro do Sul Aerodrome (SBCZ) in Acre, Brazil. The flight was intended to verify the functionality of the aircraft's VHF Omnidirectional Radio Range (VOR) equipment. The aircraft was operated by AEROBRAN Táxi Aéreo Ltda. under Visual Flight Rules (VFR).
During the final approach, the aircraft landed with its landing gear in the retracted position. Upon touchdown, the fuselage and propellers made contact with the runway, causing the aircraft to slide approximately 400 meters before coming to a complete stop near the left edge of the runway. Despite the impact, the pilot and the four passengers on board were uninjured, and the aircraft sustained only minor damage.
The investigation
CENIPA investigators examined the aircraft's maintenance records, flight logs, and the organizational culture of the operator. The investigation confirmed that the landing gear system was fully functional, and subsequent tests showed no mechanical failure or inadvertent retraction after touchdown. The investigation also revealed that the pilot had performed the flight using the ANAC code of another pilot, which was a violation of established flight plan procedures.
Furthermore, the investigation identified a pattern of informality within the company. A previously observed malfunction in the VOR equipment, noted during an earlier flight that morning, had been communicated informally to maintenance but was not recorded in the aircraft's technical logbook. Additionally, the functional test of the VOR, which was the purpose of the flight, could have been safely performed on the ground according to the maintenance manual, making the flight itself unnecessary.
Findings
- The primary cause of the incident was a failure to extend the landing gear due to a lapse in the pilot's attention and memory during the approach phase.
- An organizational culture of informality contributed to the incident, as evidenced by the failure to officially log equipment discrepancies and the presence of company employees as passengers on a non-scheduled flight.
- The pilot's attention was reduced during the approach, leading to the omission of critical landing gear checklist items.
- The lack of formal recording of technical discrepancies hindered effective airworthiness management and prevented the tracking of failure trends.