What happened
On December 2, 2019, a Hawker Beechcraft C90GT, registration PP-BSB, departed from Comandante Rolim Adolfo Amaro Aerodrome (SBJD) in Jundiaí, São Paulo, bound for Campo de Marte Aerodrome (SBMT). The flight was being conducted under Visual Flight Rules (VFR).
Upon approaching the destination, the pilot was informed by air traffic control that meteorological conditions at SBMT were below the minimums required for VFR operations. The pilot was instructed to return to the airport of origin. During the repositioning flight, the aircraft deviated from the established visual corridor and descended to 3,700 feet, which was below the minimum altitude required for the sector. The aircraft subsequently collided with treetops and the ground in a wooded area in Caieiras, São Paulo. The impact resulted in the destruction of the aircraft and the fatal injury of the pilot.
The investigation
CENIPA's investigation focused on the flight's deviation from established corridors and the pilot's response to terrain warnings. Investigators analyzed the cockpit voice recorder (CVR), which revealed that the Enhanced Ground Proximity Warning System (EGPWS) issued several critical alerts, including "Caution Terrain" and "Pull Up," but the pilot failed to take evasive action.
Technical analysis confirmed that the engines were producing power at the time of impact and no mechanical failures contributed to the accident. The investigation also examined the pilot's experience, noting he was highly qualified with significant multi-engine and instrument flight experience. Meteorological data confirmed that low cloud ceilings and reduced visibility at the destination made VFR flight impossible.
Findings
- Adverse meteorological conditions prevented the flight from proceeding to the destination under VFR.
- The pilot's decision-making process was compromised by an attempt to maintain visual flight rules despite marginal ceiling and visibility.
- The pilot experienced a loss of situational awareness, likely characterized by geographic disorientation and "tunnel vision."
- There was a failure to react to EGPWS terrain alerts, indicating an inability to act effectively during an imminent collision condition.
- The aircraft deviated from the prescribed visual corridor and descended below the required altitude for the area.