What happened
On October 1, 1994, at approximately 08:00, a Cessna 310 (registration PT-KYK) operated by Aerosita was attempting to depart from the Datas aerodrome in Minas Gerais, Brazil. The flight was a chartered mission intended to transport a political candidate and crew to various cities in the region.
During the takeoff roll on runway 21, the pilot initiated rotation too late in the runway length. This maneuver caused the aircraft's tail to strike the ground. Following the tail strike, the aircraft veered to the left with the left wing low, traveling approximately 50 meters before colliding with an embankment. The impact triggered a series of subsequent collisions with the uneven, rocky terrain, which ultimately resulted in a post-crash fire that completely destroyed the aircraft. The two crew members sustained fatal injuries, while the sole passenger was ejected from the aircraft and survived with minor injuries.
The investigation
CENIPA's investigation focused on the technical, operational, and human factors surrounding the departure. Investigators examined the aircraft's engines, which were found to be in normal working condition and capable of producing maximum power. The investigation also reviewed the aerodrome characteristics, noting that the Datas strip was a short (700-meter), unpaved runway located at a high elevation (1,255 meters), which required precise performance calculations.
Regarding the crew, investigators found that the pilot's multi-engine rating had expired in December 1993. Furthermore, the pilot lacked sufficient experience in the Cessna 310 and had demonstrated inconsistent pitch control in similar aircraft types. A critical finding involved the crew's physiological state: the crew had attended a social event involving the consumption of alcohol until 03:00, only five hours before the scheduled takeoff, leaving insufficient time for recovery or for the effects of alcohol to dissipate.
Findings
- Improper Takeoff Technique: The pilot applied an excessive pitch attitude during rotation, causing the tail strike and subsequent loss of control.
- Inadequate Planning: The crew failed to perform a rigorous pre-flight assessment of the specific performance requirements for the short, high-altitude, unpaved runway at Datas.
- Physiological Impairment: The crew had consumed alcohol less than 12 hours before the flight, likely resulting in reduced situational awareness, impaired judgment, and diminished motor coordination.
- Pilot Proficiency: The pilot had insufficient training in the Cessna 310 and was operating with an expired multi-engine qualification.
- Operational Oversight: The operator allowed the flight to proceed despite the pilot's expired multi-engine rating.