What happened
On February 5, 2001, a Lake LA-250 amphibious aircraft, registration PT-OBI, operated by Táxi Aéreo Rio Amazonas Ltda., attempted to depart from Flores Aerodrome (SWFN) in Manaus, Brazil. The mission was to transport a person requiring medical attention from a local hotel to the city.
During the takeoff roll on runway 29, witnesses observed the aircraft reaching a point of lift that raised the main landing gear off the ground, while the nose wheel remained in contact with the pavement. Despite the engine producing high power, the aircraft failed to rotate and climb. As the aircraft reached the end of the runway, it encountered an elevated terrain, causing it to descend and strike the ground approximately 50 meters past the runway threshold. The pilot, the sole occupant, sustained fatal injuries, and the aircraft was destroyed.
The investigation
CENIPA investigators established that the pilot had used a padlock to secure the control column (manche) to prevent theft during overnight parking, replacing the standard, highly visible control lock. This practice was a known habit of the pilot, who had previously aborted a takeoff a week prior due to the same error.
During the investigation, a simulation using an identical aircraft model confirmed that the flight controls were indeed locked during the takeoff attempt. Investigators also noted that the pilot's maintenance logs for the engine and propeller were not up to date, though the aircraft's airworthiness certificate was valid. Furthermore, the investigation looked into the pilot's cockpit environment, noting that pilots in the region often taxied with the door open to mitigate heat, which may have obstructed the visibility of the takeoff checklist located on the door.
Findings
- The primary cause of the accident was that the flight controls were locked by a padlock during the takeoff roll.
- The pilot experienced psychological pressure and anxiety due to the urgency of the medical transport and the imminent arrival of rain, which may have led him to rush the pre-takeoff procedures.
- The pilot failed to perform a proper free-and-correct flight control check before departure.
- Environmental factors, specifically the use of an informal method to cool the cabin by taxiing with the door open, may have hindered the pilot's ability to properly read the checklist.
Safety action
CENIPA issued the following safety recommendations to Táxi Aéreo Rio Amazonas Ltda.:
- Immediately prohibit the use of any non-approved objects for aircraft operations, specifically including improvised items used for control locks.
- Implement a training program to standardize and refresh theoretical and practical knowledge for pilots, emphasizing strict adherence to checklists.
- Establish formal operational procedures for using security devices intended to prevent aircraft theft.