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Accident
Last updated: 23 October 2017
Status:Definitief
Datum:dinsdag 28 februari 2012
Tijd:07:15
Type:Silhouette image of generic C208 model; specific model in this crash may look slightly different
Cessna 208B Grand Caravan
Luchtvaartmaatschappij:CTA - Cleiton Taxi Aéreo
Registratie: PT-PTB
Constructienummer: 208B-0766
Bouwjaar: 1999
Motoren: 1 Pratt & Whitney Canada PT6A-114A
Bemanning:slachtoffers: 1 / inzittenden: 1
Passagiers:slachtoffers: 0 / inzittenden: 0
Totaal:slachtoffers: 1 / inzittenden: 1
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:ca 0,2 km W of Manaus-Aeroclube de Flores Airport, AM (   Brazilië)
Fase: Initiële klim (ICL)
Soort vlucht:Ferry
Vliegveld van vertrek:Manaus-Aeroclube de Flores Airport, AM (SWFN), Brazilië
Vliegveld van aankomst:Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG), Brazilië
Beschrijving:
A Cessna 208B Grand Caravan was destroyed in an accident near Manaus-Aeroclube de Flores, AM. The pilot, the sole occupant, sustained fatal injuries.
The airplane took off from runway 29 on a ferry flight to Manaus-Eduardo Gomes International Airport, AM (MAO). It failed to gain enough height on takeoff and collided with a pole. The airplane came down in a wooded area just off Avenida Torquato Tapajós.
Manaus-Aeroclube de Flores Airport, AM has a single, 860 m long asphalt runway.
It appeared that the control locks were still in place and had not been removed during the preflight checks.

Probable Cause:

Individual information
a) Attitude - unspecified
To assume all the responsibilities of flight (flight notification, removal from the aircraft, inspections, etc.) almost alone, the pilot showed overconfidence in his ability to perform such a task, possibly considering it ordinary and of low complexity.
In addition, the company mechanic's participation in the preparation of the aircraft may have strengthened the confidence that the pre-flight items that may pass unnoticed would be performed by one technician.

b) Memory - contributed
The pilot forgot the control lock on the aircraft, which may have resulted from the rush to do the checklist, in which some items were not checked properly, as the existing lock model, which was less visible and was not approved for aeronautical purposes.

c) Motivation - contributed
The commander proved to be very motivated to make the supply flight quickly, so as not to impair the subsequent flight, which may have interfered with the completion of the checklist so that culminated in lock remaining in place.

Information Psychosocial
a) Team Dynamics - contributed
Although the pilot relied on mechanical help in the preparation of the aircraft, the dynamic established by them did not guarantee the execution of the tasks efficiently and safely.

Organizational Information
a) Organizational culture - contributed
The company since two years used a non-approved control lock and there was no standardization of the procedures of company manuals, which indicates that the fragile safety culture that reverberated in the accident.

b) Support Systems - contributed
The manuals of the company not clearly specified the activities that the mechanic should follow when preparing the aircraft, thus allowing gaps were created in the execution of the task.

Concerning aircraft operation
a) Cockpit coordination - contributed
The pilot in command stopped using organizational resources available to him to accomplish the task to transfer the aircraft. The copilot had not arrived and the mechanic of the company was not among its duties to perform the complete pre-flight aircraft. Thus, the commander had to perform various tasks in a relatively short time and, therefore, failed to comply with an important item in the checklist that was removal of the lock of flight controls.

b) Pilot forgetfulness - contributed
The pilot forgot to remove the control lock during inspections (internal and external). Also forgot to perform the checklist of items relating to freedom of controls (aileron and elevator), during taxi the aircraft. The realization of these checks during pre-flight or even in the taxi the aircraft would have avoided the takeoff and, therefore, the accident.

c) Managerial supervision - contributed
Inadequate supervision of maintenance management allowed the aircraft involved in the accident to possess control locks not certified as an aeronautical product.

d) Non-standard procedure - contributed
The pilot, possibly due to the rush to perform takeoff, failed to meet a number of items set out in checklist that, if realized, would alert the commands that the lock had not been removed. This item can be considered as the last barrier to prevent the accident.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 3 years and 3 months
Accident number: A-626/CENIPA/2014
Download report: Final report

Bronnen:
» Folha
» D24am


Foto's

photo of Cessna 208B Grand Caravan PT-PTB
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Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Manaus-Aeroclube de Flores Airport, AM en Manaus-Eduardo Gomes International Airport, AM bedraagt 5 km (3 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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