What happened
On July 12, 2019, a Piper PA-28-140, registration PT-CON, departed from Campo de Marte Aerodrome (SBMT) in São Paulo for a local flight near Atibaia. The flight included two pilots on board who were performing touch-and-go landing training at Fazenda Vale Eldorado Aerodrome (SDVH). During the return leg of the flight, the aircraft collided with the ground in a rural area near Atibaia, São Paulo. The impact destroyed the aircraft and caused damage to a nearby rural dwelling and fencing. Both pilots sustained fatal injuries.
The investigation
CENIPA investigators examined the wreckage and the flight history of the crew. The investigation noted a significant disparity in experience between the two pilots: the Pilot in Command (PIC) had only 56 total flying hours, while the Second in an Command (SIC) was highly experienced with over 7,700 hours. The investigation also reviewed meteorological data, which showed favorable VMC conditions with no significant weather phenomena or precipitation.
Technical analysis of the engine revealed evidence of a lean air-fuel mixture and signs that the cylinders and pistons had operated at above-normal temperatures. While the engine was still operating at the time of impact, it was producing low power. Investigators also analyzed the flight trajectory, which showed a steep angle of more than 45 degrees toward the terrain, suggesting the aircraft may have entered a stall during an attempt at an emergency landing.
Findings
- The aircraft was within weight and balance limits and had a valid Certificate of Airworthiness.
- The engine showed evidence of operating with a lean air-fuel mixture.
- The crew's lack of a pre-defined flight plan and the improvisation of the training activity may have led to inadequate risk assessment.
- A lack of clearly defined roles and responsibilities in the cabin may have hindered coordination during the emergency.
- The investigation identified inadequate application of flight controls as a contributing factor, leading to an uncontrollable stall and impact.