What happened
On November 2, 2008, a BE-P3CO (Beechcraft BE-P35) departed Rondonópolis, Mato Grosso, bound for Arapongas, Paraná, under Visual Flight Rules (VFR). The flight included an intermediate stop in Sonora, Paraná, where four passengers boarded the aircraft.
During the flight, the pilot maintained radio contact with another aircraft ahead, which provided updates on worsening weather conditions near the intended destination. As visibility and ceilings dropped significantly due to heavy rain and thunderstorms, the pilot diverted toward Paranavaí. Local witnesses reported seeing the aircraft flying at a very low altitude through heavy rain shortly before it struck the courtyard of the Nilda Campana school. The impact resulted in five fatalities (the pilot and four passengers) and severe damage to the aircraft.
The investigation
CENIPA's investigation focused on the aircraft's fuel state and the pilot's decision-making process. Investigators found that the aircraft's fuel tanks contained only residual amounts of fuel upon impact, indicating a fuel exhaustion event. While the aircraft had sufficient initial fuel for the planned route, the investigation examined whether deviations and attempts to locate suitable landing sites in poor visibility depleted the reserves.
The investigation also reviewed the pilot's preparation, noting that although the pilot was IFR-rated, the aircraft was not equipped with necessary navigation charts or maps. Furthermore, investigators looked into the operational context of the pilot working as a freelancer, which may have introduced psychological pressures and increased the pilot's workload without adequate supervisory support.
Findings
- The primary cause of the accident was fuel exhaustion, which led to engine failure during a period of low altitude and low airspeed.
- The pilot's judgment was compromised by an inadequate assessment of weather variables and fuel autonomy management.
- Inadequate flight preparation was evidenced by the absence of essential navigation charts and publications on board, preventing an IFR approach to alternative airports.
- Deteriorating meteorological conditions, including heavy rain and low ceilings, contributed to the difficulty in maintaining visual references and likely increased fuel consumption during search maneuvers.
- Potential psychological pressures and increased anxiety, possibly stemming from the freelance operational structure, may have impaired the pilot's situational awareness and decision-making.