Date:	Monday 16 September 2019
Time:	12:26
Type:	Cessna 208B Grand Caravan
Owner/operator:	TwoFlex
Registration:	PT-MHC
MSN:	208B0543
Year of manufacture:	1996
Engine model:	Pratt & Whitney Canada PT6A-114A
Fatalities:	Fatalities: 0 / Occupants: 10
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	0,6 km W of Manaus-Eduardo Gomes International Airport, AM (MAO) -   Brazil
Phase:	Take off
Nature:	Passenger - Scheduled
Departure airport:	Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG)
Destination airport:	Maués Airport, AM (MBZ/SWMW)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Cessna 208B Grand Caravan, registration PT-MHC, crashed in a wooded area shortly takeoff from runway 29 at Manaus-Eduardo Gomes International Airport in Brazil. Six occupants suffered serious injuries. The remaining four suffered minor injuries.

Thunderstorm were present in the area around the time of departure, and the associated change in wind direction and intensity caused the departure runway to change from runway 11 to 29 as the aircraft was taxiing to the runway.
At 12:24:19, the Tower controller cleared the aircraft for takeoff from runway 29. Wind was reported as 300º at 20 kt and an altimeter setting of 1011 HPa.
The take-off was carried out in heavy rain and shortly afterwards the aircraft lost height, contacted trees and crashed to the left of the extended centreline of the runway, 600 meters from the end of the runway.

Contributing factors.
- Control skills – undetermined.
While facing adverse conditions, the use of controls may have been inappropriate for the situation and may have contributed to the aircraft not being able to maintain a positive climb rate.
- Attitude – undetermined.
Familiarization with the region may have led to an attitude, on the part of the PIC, of minimizing the importance of analyzing adverse weather conditions, to the detriment of compliance with the minimum limits established by the company in its manuals.
- Training – undetermined.
It is possible that, due to possible inadequate training, the SIC did not identify the critical situation that arose shortly after the take-off in time to assist the PIC in maintaining flight control.
- Tasks characteristics – undetermined.
The characteristics present in the type of operation, compliance with schedules without the possibility of delays, due to the runway closing period, may have favored the self- imposed pressure on the part of the PIC, leading him to operate with reduced safety margins.
- Adverse meteorological conditions – a contributor.
The conditions at the time of the take-off contributed to the aircraft not being able to maintain the flight with a positive climb rate. The probable occurrence of Windshear determined that the trajectory of the aircraft was modified until its collision with the ground.
- Crew Resource Management – undetermined.
On the part of the SIC, no assertive attitude was perceived in the sense of alerting the PIC that those conditions were not favorable for takeoff. Thus, the crew decided to carry out the take-off despite the company's SOP.
- Organizational culture – undetermined.
The company encouraged compliance with the legs even though, within the planning of flights, there was not an adequate margin of time to absorb any delays. This culture may have influenced the PIC's decision-making, which, despite encountering adverse conditions, chose to take off, since the short time on the ground in the intermediate locations did not allow room for delays.
- Emotional state – undetermined.
The reports indicated that the PIC felt pressured to perform the take-off even in the weather conditions found on the day of this occurrence. Also, according to the interviewees, this pressure would be related to the fulfillment of the flight schedule and the need to keep to the scheduled times. In this way, it is possible that their assessment of the performance of the flight was influenced by the stress resulting from the pressure to complete the flight within the expected time, given the closing time of the runway for works.
- Flight planning – a contributor.
The flight planning was not carried out properly, considering that the planned schedules and routes would end after the closing time of the SBEG runway for works, provided for in the NOTAM. This meant that there was little time to adjust the legs, increasing the workload and stress in the cabin.
- Decision-making process – a contributor.
There was a wrong assessment of the meteorological conditions, which contributed to the decision of performing it in an adverse situation.
- ATS publication– undetermined.
The TWR-EG did not inform, before the take-off, of the changes in the significant weather conditions that were occurring at the terminal, which could have contributed to the PIC's decision-making.

16:00 UTC / 12:00 local time:
SBEG 161600Z 21009KT 8000 -SHRA SCT020 FEW025TCU SCT100 31/24 Q1011

16:06 UTC / 12:06 local time:
SBEG 161606Z 14014KT 2000 SHRA SCT020 FEW025TCU SCT100 25/19 Q1012

16:24 UTC / 12:24 local time:
SBEG 161624Z 27016KT 3000 TSRA BKN014 FEW025CB SCT100 22/19 Q1012

16:34 UTC / 12:34 local time:
SBEG 161634Z 27017G46KT 4000 1500W TSRA BKN012 FEW025CB SCT100 20/18 Q1011

17:00 UTC / 13:00 local time:
SBEG 161700Z 31008KT 4000 -TSRA SCT010 BKN020 FEW025CB 21/20 Q1011 RETSRA

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photo (c) Ulrich Hoppe; Manaus-Eduardo Gomes International Airport, AM (MAO); 23 January 2019

Date/time	Contributor	Updates
15-Mar-2024 19:48	ASN	Updated [Accident report]