What happened
On April 28, 2017, a Piper PA-30 aircraft, registration PT-CHT, departed from Campos dos Amarais Aerodrome in Campinas, Brazil, for a local instructional flight. The crew consisted of a flight instructor and a student pilot, the latter of whom was conducting his first flight in a multi-engine aircraft.
During the flight, the aircraft entered a downward spin, resulting in a high-energy impact with treetops and the ground in a rural area near Itapira. The wreckage showed evidence of a pitch-down attitude and significant structural torsion. The impact caused substantial damage to the airframe, and both crew members sustained fatal injuries.
The investigation
CENIPA investigators analyzed flight footage showing the aircraft's final trajectory in a downward spin. The investigation established that the aircraft was within weight and balance limits and that all required airworthiness and maintenance records were up to date. Meteorological conditions at the time were favorable for flight.
The investigation focused on the execution of a stall exercise. Evidence suggested the instructor performed the maneuver using parameters that deviated from the established safety standards of the flight school. The investigation concluded that the aircraft was placed in an excessive pitch-up attitude, leading to a stall that transitioned into an unrecoverable spin. Notably, the Piper PA-30 was not certified for spin maneuvers, making recovery from such an aggressive attitude extremely difficult.
Findings
- The instructor's use of non-standard, daring maneuvers to demonstrate stall characteristics led to the loss of control.
- A lack of organizational oversight at the aeroclub allowed for flight indiscipline and the use of non-standard instructional techniques.
- An organizational culture characterized by excessive informality and a lack of formal supervision contributed to the occurrence.
- The instructor's personal tendency toward high-risk maneuvers and a lack of standardized monitoring mechanisms facilitated the deviation from safety protocols.