ASN Wikibase Occurrence # 225215
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| Date: | Saturday 18 May 2019 |
| Time: | |
| Type: |  Cessna T210N Turbo Centurion II |
| Owner/operator: | Private |
| Registration: | PR-DVR |
| MSN: | 21063393 |
| Year of manufacture: | 1979 |
| Fatalities: | Fatalities: 1 / Occupants: 4 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Belém, Pará -
 Brazil
|
| Phase: | Take off |
| Nature: | Private |
| Departure airport: | Belém-Protásio de Oliveira Airport, PA (SBJC) |
| Belém-Protásio de Oliveira Airport, PA (SBJC) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Cessna T210N Turbo Centurion II crashed into a house after taking off from Belém-Protásio de Oliveira Airport, PA (SBJC).
Shortly after the take-off, black smoke coming from the aircraft was observed. The pilot tried to return to the airport, making a left turn. However, it lost altitude, colliding with a residence.
The aircraft had substantial damage.
The pilot suffered fatal injuries, two passengers suffered serious injuries and the other passenger suffered minor injuries.
Contributing factors.
- Control skills – a contributor.
The inadequacy in the use of the flight controls led to the loss of control of the aircraft and the consequent collision with a building, aggravating the consequences of the occurrence.
- Attitude – undetermined.
The fact that there was a history of not using the checklist by the pilot in question, indicated a complacent attitude towards the correct execution of the aircraft's procedures, which may have contributed to deteriorating the quality of the air/fuel mixture, due to the respective pump has remained on after the take-off.
- Piloting judgment – undetermined.
The fact that the pilot made a left turn right after the take-off with low power and low altitude may have been the result of an inadequate assessment of the aircraft's maneuverability under those conditions, which resulted in the loss of control of the plane.
- Aircraft maintenance – a contributor.
The incorrect storage of the aircraft, over a period of approximately two years, resulted in the installation of corrosion processes in several systems and components. Associated with this, the fulfillment of inspections that did not detect critical conditions in its components contributed to a reduction in power during the take-off and to this accident.
- Memory – undetermined.
The pilot was not familiar with operating turbocharged aircraft. Furthermore, there was a history of not using the checklist. Thus, it is possible that the auxiliary fuel pump was forgotten turned on during the take-off, which probably contributed to the unbalance of the air/fuel mixture.
- Insufficient pilot’s experience – undetermined.
The pilot's little experience in operating aircraft equipped with turbochargers, combined with the fact that there was a history of not using a checklist by the pilot in question, may have influenced his decision to leave the auxiliary fuel pump on, which, probably contributed to deteriorating the quality of the fuel/air mixture, flooding the engine.
- Decision-making process – undetermined.
The decision to return to the Aerodrome may have contributed to the evolution of the occurrence, since the conditions faced at the time (low power and low height) suggested that this maneuver might not be the most indicated in that operational context.
- Managerial oversight – a contributor.
The maintenance procedures of the inspections of 50h, 100h and Special Items, carried out by the maintenance organization, were not complied with as prevised in the manufacturer's service manual (D2057-3-TR14).
This fact demonstrated failures in the managerial supervision of the execution activities, in the technical scope, by the maintenance organization, contributing to this occurrence
Accident investigation:
 |
|
Sources:
https://g1.globo.com/pa/para/noticia/2019/05/18/aviao-de-pequeno-porte-cai-sobre-residencia-em-belem.ghtml
https://www.noticiasaominuto.com/mundo/1254904/brasil-aeronave-cai-em-cima-de-casa-e-faz-um-morto
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 18-May-2019 19:35 | Victor | Added |
| 18-May-2019 19:35 | harro | Updated [Aircraft type, Cn] |
Corrections or additions? ... Edit this accident description
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