What happened
On October 22, 2017, a Cessna 210N, registration PT-ORU, departed from Itaituba Aerodrome (SBIH) in Pará, Brazil, for a local flight. The aircraft was carrying one pilot and four passengers. During a celebration for Aviator's Day, the aircraft performed a low-altitude pass over a hangar without notifying air traffic services.
Following this pass, the pilot attempted an aerobatic maneuver (a loop/tonneaux). During the execution of this maneuver, the aircraft entered an aggressive attitude toward the ground, causing it to collide with terrain in a vegetated area approximately 350 meters from the runway. The impact destroyed the aircraft and the engine struck a residential wall, causing damage to the structure. All five occupants sustained fatal injuries.
The investigation
CENIPA's investigation established that the aircraft was not certified for aerobatic flight, as its airworthiness certificate categorized it as "Normal." While the engine was producing power at the time of impact and the aircraft was within weight and center of gravity limits, the investigation identified several critical human and organizational factors.
Investigators found that the pilot had a blood alcohol content of 0.0215%. Although this was below the legal limit for prohibition under Brazilian regulation, the level was sufficient to potentially impair attention, coordination, and decision-making. Furthermore, the investigation noted a lack of formal organizational processes by the operator to monitor and control flight activities, which allowed for the use of the aircraft in an unauthorized and unsafe manner.
Findings
- Flight Indiscipline: The pilot performed unauthorized low-altitude passes and aerobatic maneuvers in an aircraft not certified for such operations.
- Pilot Error: The pilot incorrectly assessed the aircraft's capabilities and failed to maintain proper control during the maneuver.
- Impaired Judgment: The pilot's exhibitionist attitude and self-confidence, potentially exacerbated by the presence of alcohol, hindered the perception of flight risks.
- Organizational Failure: A lack of formal oversight and a culture of informal, risky practices among local pilots contributed to the occurrence.
Safety action
CENIPA issued several recommendations, including:
- A request for ANAC to work with the Itaituba Aerodrome operator to ensure safety events are reported.
- A recommendation to evaluate lowering the legal blood alcohol limit for civil aircraft crew from 0.04% to 0.00% to align with terrestrial transit laws.