What happened
On April 11, 1995, a Cessna 208 Caravan, registered as PT-OGO, was conducting a local flight at the Luziânia Aerodrome in Goiás, Brazil. The flight was part of an initial check-out process for four newly admitted co-pilots for the operator Brasil Central. The crew included the pilot in command, a trainee co-pilot, and a Civil Aviation Inspector (INSPAC).
During the evaluation of the third co-pilot, the crew performed an emergency training maneuver simulating an engine failure. During this procedure, the aircraft executed a short approach and struck the terrain before reaching the runway threshold. The impact caused the aircraft to lose control, striking trees and ground depressions before coming to rest 20 meters from the right side of the runway. The aircraft was a total loss, but all occupants emerged uninjured.
The investigation
The CENIPA investigation established that the engine was functioning normally and that the propeller was in a high-power state at the moment of impact. Investigators found that the aircraft struck the ground in a stalled condition at an angle of approximately ten degrees.
Technical analysis revealed that the training technique used was not recommended; the maneuver was performed with the propeller at minimum pitch, which significantly increased the sink rate to 1,000 feet per minute or more, compared to the standard 500 feet per minute achieved with a feathered propeller. Furthermore, the instructor's reaction time was insufficient, as the delay in applying power—compounded by the 5 to 8 seconds required for the engine to reach effective power—prevented the recovery of the aircraft.
Findings
- Human Factors: The pilot in command experienced significant fatigue and diminished attention due to having completed 34 landings and over five hours of flight time on that single day. This led to a failure in judgment and a delayed application of power.
- Operational Deficiencies: The company's training program was found to be insufficient, as it did not include simulator training or specific instruction for engine failure landings. Additionally, the instructor was evaluating an excessive number of students simultaneously.
- Crew Coordination: There was a lack of effective cockpit coordination; the inspector's position prevented a full view of the flight situation, and the trainee co-pilot lacked the experience to properly assess the deteriorating flight parameters.
- Maintenance and Safety Management: The operator lacked a formal Accident Prevention Program and did not have personnel qualified in engine trend analysis for the PT6A-114 engine.