What happened
On March 11, 2015, at approximately 23:25 UTC, a Cessna 210L, registration PT-JEE, was performing a transport flight from Santo Antônio do Iça to Tabatinga, Brazil. The aircraft was carrying one pilot and five passengers.
During the flight, weather conditions deteriorated from visual meteorological conditions (VMC) to instrument meteorological conditions (IMC) due to heavy rain. While the pilot initially reported visual contact with the runway threshold at Tabatinga, the lack of suitable landing conditions led to a decision to execute a traffic pattern for the opposite runway. While maneuvering on the downwind leg for runway 30, the pilot lost visual references and the aircraft impacted trees near the runway. The impact caused substantial damage to the Cessna 210L, including the separation of the engine and the tail cone, and a brief engine fire. All six occupants sustained light injuries and evacuated the wreckage through openings in the fuselage.
The investigation
CENIPA's investigation focused on the pilot's decision-making and instrument accuracy. Investigators found that although the pilot was qualified for VMC, his instrument flight rating (IFRA) had been expired since 2013. Despite the deteriorating weather and approaching nightfall, the pilot proceeded toward the destination.
Crucially, the investigation established that the pilot was flying with an incorrect altimeter setting. While the Tabatinga radio station had provided a setting of 1007 hPa, the pilot had the altimeter adjusted to 1009 hPa. This error likely caused the aircraft to fly at a lower altitude than indicated on the instruments, contributing to the collision with the tree canopy, which was situated at approximately 328 feet.
Findings
- Incorrect altimeter setting leading to an underestimated altitude.
- The pilot's instrument flight rating (IFRA) was expired.
- Adverse meteorological conditions and heavy rain.
- Poor situational awareness and degraded perception of the external environment.
- Errors in pilot judgment and flight discipline regarding the decision to continue the approach in deteriorating weather.