What happened
On May 22, 2009, a Beechcraft B300, registration PR-MOZ, departed Congonhas Aerodrome (SBSP) in São Paulo, bound for the Terravista Aerodrome (SBTV) in Porto Seguro, Bahia. During the approach to runway 15, the aircraft encountered heavy rainfall and poor visibility. While attempting the landing, the aircraft struck trees approximately 900 meters from the runway threshold. Following the initial impact, the aircraft continued to fly for an additional 700 meters before striking further trees and ultimately impacting the ground. The accident resulted in 14 fatalities, including both crew members and 12 passengers. The aircraft was destroyed upon impact.
The investigation
The CENIPA investigation focused on the meteorological conditions and the crew's decision-making process. Investigators analyzed cockpit voice recorder (CVR) data, which revealed that the crew was aware of deteriorating weather conditions. Specifically, information from REDEMET indicated that Porto Seguro (SBPS) was expected to be closed for visual operations due to weather. While the crew briefly regained visual contact with the runway during a GPS-based procedure, the investigation noted that the pilot had not established a clear contingency plan in the briefing should visual contact be lost.
Findings
- The crew attempted a visual approach despite being aware of meteorological reports indicating that the local area was operating below visual minimums.
- The aircraft was utilizing unauthorized or improvised GPS procedures to navigate the traffic pattern.
- Heavy rain and low cloud ceilings significantly degraded visibility during the final approach.
- Obstacles, including trees, were present within the approach and transition areas of the aerodrome.
- The crew failed to establish a clear procedure during the briefing for situations where visual contact with the runway could not be maintained.