What happened
On February 15, 2000, a Cessna 208, registration PT-OPA, was conducting flight instruction at the Luziânia Aerodrome in Goiás, Brazil. The flight was intended to prepare the pilot for an upcoming command checkride. During the training, the crew attempted to simulate an engine failure after takeoff procedure.
While performing the third repetition of the maneuver, the aircraft reached an altitude of 50 and a speed of 90 knots. As the crew attempted to execute the return-to-runway procedure, the aircraft experienced a significant loss of altitude during the turn to align with runway 29. The decision to initiate a go-around was made too late. During the go-around, the crew had to execute a left turn to avoid obstacles, including bushes and hangars. This maneuver caused the left wingtip to strike the runway surface. Despite the impact, the instructor regained control, and the aircraft completed a normal landing.
The investigation
CENIPA's investigation focused on why a high-risk emergency maneuver was being practiced in the aircraft rather than in a flight simulator, as prescribed by the operator's training program. The investigation examined the flight crew's coordination, the adequacy of the training syllabus, and the oversight provided by the Federal Police Aviation Division (DAOP). Investigators also reviewed the aircraft's maintenance records and the pilot's proficiency, finding the aircraft airworthy and the crew's licenses valid.
Findings
- Unauthorized Training: The crew was performing an engine-failure simulation that was explicitly required to be conducted in a synthetic flight simulator due to its high risk, not in the actual aircraft.
- Delayed Decision Making: The decision to initiate the go-around was delayed, and the crew failed to maintain the minimum safety altitude of 300 feet.
- Poor Crew Coordination: There was a lack of effective cockpit coordination between the instructor and the pilot, leading to an improper approach alignment and an unsafe altitude during the maneuver.
- Lack of Oversight: The DAOP lacked a dedicated instruction section to supervise and standardize flight training, which contributed to the execution of non-standardized and dangerous procedures.
- Operational Complacency: The crew demonstrated low situational awareness and complacency by attempting a high-risk maneuver in the aircraft that was not part of their approved training program.