What happened
On March 28, 1998, a Beech A-35, registration PP-IPJ, departed from Cacoal Airport (SWKK) in Rondônia, Brazil, bound for Vilhena. The aircraft was operated by a single pilot. Shortly after takeoff, at an altitude of approximately 800 feet, the engine failed.
In an attempt to return to the runway, the pilot executed a left-hand turn. After completing this maneuver, the aircraft was not properly aligned with the runway, prompting the pilot to perform a second, high-bank turn to correct the heading. During this aggressive maneuvering, the aircraft lost airspeed and entered a stall. The aircraft subsequently struck the ground approximately 1,500 meters from runway 19 at a steep angle. The impact was followed by a post-crash fire that completely destroyed the aircraft. The pilot sustained fatal injuries during the impact.
The investigation
CENIPA's investigation focused on the sequence of events following the engine failure and the pilot's decision-making process. Investigators noted that the pilot had recently completed a course in Porto Velho and was reportedly anxious to return to his home in Vilhena. This perceived urgency may have influenced the decision to depart from runway 01, which features an uphill gradient, rather than taxiing to the more suitable runway 19.
Because the engine was largely consumed by the post-crash fire, detailed mechanical testing was not possible. Furthermore, the aircraft's flight logs and engine maintenance records were unavailable at the time of the investigation. Investigators also noted that the pilot chose to attempt a return to the runway despite being at a low altitude and low airspeed, rather than opting for an immediate forced landing in the available clear areas near the departure path.
Findings
- Deficient judgment: The pilot failed to correctly assess the feasibility of returning to the runway and did not recognize that an immediate forced landing in nearby suitable terrain could have been safer.
- Deficient application of controls: The pilot's maneuvers to realign the aircraft resulted in a loss of airspeed and subsequent stall.
- Human factors: The pilot's perceived haste and anxiety to reach his destination may have negatively impacted his attention and emergency management decision-making.
- Engine failure: An engine failure occurred at 800 feet, though the exact cause (whether mechanical failure or pilot error regarding fuel management) could not be definitively determined due to the destruction of the engine.