What happened
On July 3, 2002, a Piper PA-32RT-300T, registration G-BMEV, departed Cascais Municipal Aerodrome at 10:53 UTC as part of a group flight organized by the International Fellowship of Flying Rotarians. The flight was destined for Vilar da Luz. Approximately 12 minutes into the flight, the pilot contacted Lisbon Flight Information Service (FIS) to request a return to Cascais, citing the inability to continue under Visual Flight Rules (VFR) due to deteriorating meteorological conditions.
Following instructions from the FIS to fly toward Cabo da Roca and follow the coastline, the aircraft encountered worsening visibility. During the flight, the pilot confirmed they were in contact with the ground but noted poor visibility. At 11:20:22 UTC, the aircraft struck the terrain in the Serra de Sintra near Peninha. The impact destroyed the aircraft, and there were 4 fatalities among the occupants.
The investigation
The GPIAAF investigation examined the flight history, meteorological conditions, and air traffic management (ATM) procedures. The investigation established that the pilot had omitted the Cabo da Roca waypoint during the initial readback of departure instructions. Furthermore, the investigation scrutinized the coordination between Cascais Tower and Lisbon FIS. It was found that the controller at the ground position had recorded aircraft callsigns on an unformatted piece of paper to later activate flight progress strips, a practice that deviated from standard procedures.
Findings
- The primary cause of the accident was controlled flight into terrain (CFIT) while the pilot was attempting to navigate back to the aerodrome in deteriorating weather.
- The pilot was operating under VFR but reported poor visibility and difficulty maintaining visual contact with the ground.
- There was a lack of effective coordination regarding the specific reporting point (Cabo da Roca) during the initial departure phase, as the pilot initially failed to acknowledge the waypoint.
- Air traffic control procedures at Cascais Tower regarding the manual recording of aircraft transfers were found to be inadequate and inconsistent with established standards.