Incident Overview

Date: Tuesday 28 February 2012
Aircraft Type: Cessna 208B Grand Caravan
Owner/operator: CTA – Cleiton Taxi A‚reo
Registration Number: PT-PTB
Location: ca 0,2 km W of Manaus-Aeroclube de Flores Airport, AM – ÿ Brazil
Phase of Flight: Initial climb
Status: Destroyed, written off
Casualties: Fatalities: 1 / Occupants: 1
Component Affected: Cessna 208B Grand Caravan Control LocksCessna 208B Grand Caravan Control Locks
Investigating Agency: CENIPACENIPA
Category: Accident
A Cessna 208B Grand Caravan was destroyed during an accident near Manaus-Aeroclube de Flores, AM, resulting in the fatal injuries of the pilot. The aircraft took off from runway 29 on a ferry flight to Manaus-Eduardo Gomes International Airport, MAO. The pilot, alone, failed to gain sufficient height on takeoff and collided with a pole. The airplane descended in a wooded area off Avenida Torquato Tapaj¢s, demonstrating a lack of control and a failure to adhere to pre-flight procedures. The aircraft’s control locks remained in place, suggesting a potential oversight in their removal, and the pilot’s overconfidence in his ability to perform tasks without proper verification contributed to the incident. The company mechanic’s participation in aircraft preparation may have exacerbated this issue by strengthening the confidence that pre-flight items were not thoroughly checked. The pilot?s forgetfulness regarding the control lock removal, coupled with a failure to complete the checklist for freedom of controls, significantly impacted the aircraft’s performance and led to the accident.A Cessna 208B Grand Caravan was destroyed during an accident near Manaus-Aeroclube de Flores, AM, resulting in the fatal injuries of the pilot. The aircraft took off from runway 29 on a ferry flight to Manaus-Eduardo Gomes International Airport, MAO. The pilot, alone, failed to gain sufficient height on takeoff and collided with a pole. The airplane descended in a wooded area off Avenida Torquato Tapaj¢s, demonstrating a lack of control and a failure to adhere to pre-flight procedures. The aircraft’s control locks remained in place, suggesting a potential oversight in their removal, and the pilot’s overconfidence in his ability to perform tasks without proper verification contributed to the incident. The company mechanic’s participation in aircraft preparation may have exacerbated this issue by strengthening the confidence that pre-flight items were not thoroughly checked. The pilot?s forgetfulness regarding the control lock removal, coupled with a failure to complete the checklist for freedom of controls, significantly impacted the aircraft’s performance and led to the accident.

Description

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 Tapaj¢s. 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. 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.

Source of Information

http://www1.folha.uol.com.br/cotidiano/1054503-aviao-monomotor-cai-apos-decolagem-e-deixa-um-morto-em-manaus.shtmlhttp://www1.folha.uol.com.br/cotidiano/1054503-aviao-monomotor-cai-apos-decolagem-e-deixa-um-morto-em-manaus.shtml

Primary Cause

Lack of proper control lock removal during pre-flight inspections, combined with a failure to complete checklist items related to freedom of controls, and pilot’s overconfidence.Lack of proper control lock removal during pre-flight inspections, combined with a failure to complete checklist items related to freedom of controls, and pilot’s overconfidence.

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