What happened
On January 19, 2017, a Beechcraft C90GT, registration PR-SOM, crashed into the waters of Paraty Bay, Brazil, during an approach to Paraty Aerodrome. The flight, which originated from Campo de Marte Aerodrome in São Paulo, was carrying one pilot and four passengers.
During the first approach attempt, the pilot extended the landing gear, which triggered a significant increase in the rate of descent and a 'Sink Rate' alert. Consequently, the pilot aborted the first attempt, intending to wait for weather improvements. However, approximately two minutes later, a second approach was initiated. During this second attempt, the aircraft entered a region of restricted visibility characterized by heavy rainfall and a lack of ground references. The aircraft subsequently experienced a loss of control and impacted the water with a high bank angle. The impact destroyed the aircraft, and all five occupants perished.
The investigation
CENIPA's investigation focused on the meteorological conditions, the pilot's decision-making, and the operational environment. Investigators examined the aircraft's maintenance records, which were found to be up to date, and confirmed there were no mechanical failures or system malfunctions that contributed to the accident.
Analysis of the flight conditions revealed that the aerodrome only permitted operations under Visual Flight Rules (VFR). At the time of the accident, heavy rain and reduced horizontal visibility—estimated at 1,500 meters—were present, which fell below the minimum requirements for VFR operations. The investigation also analyzed the pilot's emotional state, noting evidence of high stress and anxiety during the final moments of the flight. Furthermore, investigators looked into the local aviation culture, which historically placed a high value on pilots who completed landings despite adverse weather.
Findings
- Adverse meteorological conditions: Heavy rainfall and visibility levels below VFR minimums significantly impeded safe operations.
- Inadequate decision-making: The pilot's decision to proceed with a second approach attempt despite the deteriorating weather and the failure of the first attempt contributed to the accident.
- Spatial disorientation: The combination of low visibility, a featureless terrain over the water, and high G-loads likely induced vestibular and visual illusions, leading the pilot to lose control.
- Operational culture: A local culture within the executive aviation community that rewarded landing in difficult conditions likely exerted self-imposed pressure on the pilot to attempt the landing.
- Emotional state: High levels of stress and anxiety were identified in the pilot during the approach.