Crash of a Cessna 208 Caravan I in Boituva: 2 killed
Date & Time:
May 11, 2022 at 1205 LT
Operator:
Registration:
PT-OQR
Survivors:
Yes
Schedule:
Boituva - Boituva
MSN:
208-0219
YOM:
1992
Crew on board:
1
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total hours on type:
1861.00
Aircraft flight hours:
9530
Circumstances:
The single engine airplane departed Boituva Aerodrome on a local skydiving flight, carrying 15 skydivers and one pilot. After takeoff, while climbing, the pilot encountered engine problems. He attempted an emergency landing in an open field when the airplane successively impacted an embankment and a fence before coming to rest upside down in a grassy area. Two passengers were killed, nine were injured and five escaped unhurt. The airplane was damaged beyond repair.
Probable cause:
Contributing factors:
- Training – undetermined.
The frequent and improper use of the EPL (Emergency Power Lever) during emergency landing training throughout the aircraft’s operation may have contributed to engine degradation.
- Work-group culture – undetermined.
The recurring improper use of the EPL by multiple pilots during the operation of the aircraft may have contributed to engine degradation.
- Handling of aircraft flight controls – undetermined.
It is possible that the pilot's use of the aircraft’s EPL was inappropriate and contributed to the severity of the accident.
- Aircraft maintenance – a contributor.
Given the large number of seat belts that detached as a result of the shearing of their floor attachment brackets and their corroded condition, it was determined that the maintenance actions were not effective in ensuring the integrity and reliability of these materials, which contributed to the injuries sustained by the parachutists during the emergency landing.
- Managerial oversight – a contributor.
The oversight of the operational procedures related to the use of the EPL was not effective in identifying the risks associated with its use in disagreement with the aircraft manufacturer’s specifications.
- Training – undetermined.
The frequent and improper use of the EPL (Emergency Power Lever) during emergency landing training throughout the aircraft’s operation may have contributed to engine degradation.
- Work-group culture – undetermined.
The recurring improper use of the EPL by multiple pilots during the operation of the aircraft may have contributed to engine degradation.
- Handling of aircraft flight controls – undetermined.
It is possible that the pilot's use of the aircraft’s EPL was inappropriate and contributed to the severity of the accident.
- Aircraft maintenance – a contributor.
Given the large number of seat belts that detached as a result of the shearing of their floor attachment brackets and their corroded condition, it was determined that the maintenance actions were not effective in ensuring the integrity and reliability of these materials, which contributed to the injuries sustained by the parachutists during the emergency landing.
- Managerial oversight – a contributor.
The oversight of the operational procedures related to the use of the EPL was not effective in identifying the risks associated with its use in disagreement with the aircraft manufacturer’s specifications.
Final Report:
