What happened
On November 27, 2001, an EMB-711C aircraft, registration PT-NGL, departed from Matupá, Mato Grosso, bound for Nova Xavantina. The flight was carrying the pilot and three passengers. During the flight, witnesses observed the aircraft flying at a very low altitude between the treetops and the cloud base near the Vilas Boas Post.
Shortly after being spotted, the aircraft entered the clouds. Witnesses observed the aircraft emerging from the clouds with its right wing structurally separated from the fuselage. The aircraft then collided with trees and the ground at a steep 60-degree angle. The impact resulted in four fatalities (the pilot and three passengers) and the total destruction of the aircraft.
The investigation
CENIPA's investigation established that the pilot, while holding a valid commercial pilot license for single-engine land aircraft, was not rated for Instrument Flight Rules (IFR). At the time of the accident, meteorological conditions were unfavorable for Visual Flight Rules (VFR) operations.
The investigation also revealed that the aircraft's airworthiness certificate was suspended and its maintenance records, including the annual inspection, were outdated. Investigators found that the engine was still producing power at the moment of impact, as evidenced by the depth of the wreckage in the soil. The investigation focused heavily on the decision-making process leading to the takeoff.
Findings
- Pressure from the owner: The pilot was subjected to significant psychological pressure from the aircraft owner, who used an authoritative stance and threats of dismissal to compel the pilot to fly despite the poor weather.
- Improper decision-making: The pilot made an erroneous risk assessment by choosing to depart in weather conditions that were unsuitable for his VFR-only rating.
- Complacency: The pilot exhibited a passive attitude by yielding to the interests of the contractor at the expense of flight safety.
- Inadequate oversight: There was a lack of management supervision regarding the planning and execution of the flight operation.
- Unairworthy aircraft: The aircraft was operating with a suspended airworthiness certificate and overdue maintenance inspections.