What happened
On December 8, 2021, a Piper PA-31T1 operated by Abelha Táxi Aéreo e Manutenção LTDA was performing an aeromedical transport mission from Cuiabá to Brasnorte, Mato Grosso. The flight, carrying two pilots and two passengers, was operating under visual flight rules (VFR) for its final approach.
As the crew performed the visual traffic pattern for the Brasnorte aerodrome, they misidentified the landing strip. The aircraft approached and landed on a dirt road located on a private property, roughly 1 km away from the intended runway. During the landing roll, the aircraft's landing gear collapsed, causing substantial damage to the airframe. All four occupants of the PR-BBZ escaped the incident without injury.
The investigation
CENIPA's investigation confirmed that the pilots were fully qualified, holding valid commercial licenses and instrument ratings, with significant multi-engine experience. The aircraft was airworthy, with all maintenance records up to date and the weight and balance within limits. Meteorological conditions at the time were favorable for flight.
The investigation focused on the crew's transition from GPS-guided flight to visual references. While the pilots had operated at this location before, the frequency of flights to this specific aerodrome was low. The investigators noted that the dirt road's orientation deviated by approximately 20 degrees from the actual runway heading, and the physical characteristics of the road were similar enough to the runway to cause confusion.
Findings
- Reduced situational awareness and a failure to recognize external environmental cues led to the geographical disorientation during the traffic pattern.
- Inadequate crew resource management, specifically a lack of effective task sharing and a failure by both pilots to effectively confirm the landing site during the final approach.
- Loss of visual contact with the intended runway during the circuit contributed to the operational error.