What happened
On September 14, 2001, a Beechcraft A36, registration PT-ITE, was performing a cargo flight transporting bank bags from Videira to Santa Terezinha, in the state of Santa Catarina. The aircraft had previously departed from Florianópolis but had diverted to Videira due to unfavorable weather conditions at the destination.
Upon receiving information that the destination aerodrome had returned to VFR conditions, the pilot decided to proceed. To avoid cloud layers, the pilot elected to fly at an altitude of 3,000ft, attempting to navigate below the cloud base. During the flight, the aircraft entered a cloud formation, causing the pilot to lose visual contact with the ground. In an attempt to maintain control, the pilot applied power and increased the pitch; however, the right wing struck a palm tree, leading to a sequence of impacts with trees and the terrain. The aircraft caught fire upon impact and was destroyed. The pilot sustained serious injuries.
The investigation
CENIPA's investigation focused on the flight planning and the pilot's decision-making process. The investigation established that while the pilot was highly experienced and the aircraft was airworthy and within weight limits, the flight was conducted in a manner that bypassed necessary safety margins. The investigation examined the meteorological conditions, the use of GPS for navigation, and the terrain elevations along the route, which included peaks reaching up to 4,006ft.
Findings
- The pilot's decision to maintain an altitude of 3,000ft was inadequate, as the surrounding terrain featured elevations of 3,422ft and 4,006ft.
- Inadequate flight planning occurred because the pilot relied heavily on GPS navigation without sufficiently consulting aeronautical charts regarding terrain obstructions.
- Excessive confidence in local familiarity and GPS technology led to a failure to prepare for the specific risks of the route.
- The pilot's decision-making was compromised by the attempt to maintain VFR conditions in an area where the cloud ceiling prevented visual references.
- The aircraft entered IFR conditions while the pilot was attempting to fly under VFR rules, leading to a loss of situational awareness.