Incident Overview

Date: Monday 16 September 2019
Aircraft Type: Cessna 208B Grand Caravan
Owner/operator: TwoFlex
Registration Number: PT-MHC
Location: 0,6 km W of Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG) – ÿ Brazil
Phase of Flight: Take off
Status: Destroyed, written off
Casualties: Fatalities: 0 / Occupants: 10
Component Affected: Cessna 208B Grand CaravanCessna 208B Grand Caravan
Investigating Agency: CENIPACENIPA
Category: Accident
A Cessna 208B Grand Caravan crashed in a wooded area near Manaus-Edu Gomes International Airport after takeoff from runway 29 due to a combination of factors related to weather conditions and pilot actions. The pilot initiated takeoff despite adverse wind conditions and a change in runway designation, ultimately resulting in a significant loss of altitude and a collision with the runway edge. The incident highlights a failure to adequately address potential weather risks and a lack of proactive risk mitigation strategies, potentially influenced by organizational culture and pilot pressure to meet schedule constraints.A Cessna 208B Grand Caravan crashed in a wooded area near Manaus-Edu Gomes International Airport after takeoff from runway 29 due to a combination of factors related to weather conditions and pilot actions. The pilot initiated takeoff despite adverse wind conditions and a change in runway designation, ultimately resulting in a significant loss of altitude and a collision with the runway edge. The incident highlights a failure to adequately address potential weather risks and a lack of proactive risk mitigation strategies, potentially influenced by organizational culture and pilot pressure to meet schedule constraints.

Description

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 300§ 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.

Source of Information

https://g1.globo.com/am/amazonas/noticia/2019/09/16/aviao-de-pequeno-porte-cai-proximo-a-aeroporto-de-manaus.ghtml, https://amazonas1.com.br/manaus/aviao-de-pequeno-porte-cai-em-manaus-minutos-apos-decolar/https://g1.globo.com/am/amazonas/noticia/2019/09/16/aviao-de-pequeno-porte-cai-proximo-a-aeroporto-de-manaus.ghtml, https://amazonas1.com.br/manaus/aviao-de-pequeno-porte-cai-em-manaus-minutos-apos-decolar/

Primary Cause

Unsuitable weather conditions and pilot decision-making leading to a failure to adequately assess and mitigate risks associated with adverse wind conditions and runway changes.Unsuitable weather conditions and pilot decision-making leading to a failure to adequately assess and mitigate risks associated with adverse wind conditions and runway changes.

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