What happened
On August 15, 1999, at approximately 09:30, a Cessna T 210 L, registration PT-JQQ, was performing a scenic flight from the Sobral Aerodrome in Ceará, Brazil, with four occupants on board. During the takeoff roll on runway 10, the aircraft began striking its tail against the pavement at intervals, leaving visible marks on the runway while continuing to accelerate.
Immediately after liftoff, the aircraft experienced a rapid increase in bank and pitch. The left wing dropped sharply, and the aircraft entered an inverted flight attitude. The aircraft subsequently lost altitude and collided with the ground, striking a tree before impacting the terrain. The impact triggered a massive post-crash fire that consumed the aircraft. All four occupants (one pilot and three passengers) died at the scene.
The investigation
CENIPA's investigation revealed that the individual operating the aircraft was not a licensed airplane pilot, holding only an ultralight pilot certificate. The investigation established that the pilot lacked the necessary medical certification and training for this specific aircraft type. Furthermore, the aircraft's maintenance logs for the engine and propeller were outdated, and recent maintenance had been performed inadequately.
Investigators found significant errors in flight planning and aircraft configuration. The pilot had fueled only the left wing with 110 liters of fuel, leaving the right wing with only 50 liters, based on a false belief that the tanks were interconnected. Additionally, the elevator trim was found set to an extreme nose-up position (8 degrees), a setting the pilot had intentionally chosen in an attempt to make the aircraft lift off automatically.
Findings
- Unqualified Pilot: The operator lacked the legal certification and training required to operate a Cessna T 210 L.
- Improper Weight and Balance: The asymmetrical fueling of the wings created a heavy left-wing condition, which, combined with a 10-knot crosswind, caused the aircraft to veer left during takeoff.
- Erroneous Flight Technique: The extreme nose-up trim setting prevented the aircraft from accelerating to a safe takeoff speed and induced a critical angle of attack.
- Human Factors: The pilot demonstrated a pattern of overconfidence, disregard for safety regulations, and a lack of technical knowledge regarding the aircraft's fuel system.
- Physical Limitations: The pilot was suffering from a leg injury that may have hindered the ability to use the right rudder pedal to counteract the leftward drift.