What happened
On September 7, 2014, a Cessna 172R, registration PR-TOT, was performing a flight from Aeródromo Marechal Rondon to Aeródromo Comandante Gastão (SDVI) in Tangará da Serra, Mato Grosso. The aircraft was carrying a pilot and two passengers.
During the landing attempt on runway 15, the aircraft experienced two heavy touches on the runway, prompting the pilot to initiate a go-around (missed approach). During this maneuver, the aircraft collided with overhead electrical power lines located near the airfield. The impact caused the aircraft to strike the ground and subsequently catch fire. The collision resulted in the deaths of the pilot and one passenger, while the second passenger sustained minor injuries.
The investigation
CENIPA's investigation focused on the sequence of events during the approach and the environmental conditions at the airfield. Investigators examined the aircraft's engine, a Lycoming IO-360-L2A, and found no mechanical failures that contributed to the accident; the engine was operational at the time of impact.
The investigation also reviewed the airfield's infrastructure. While a wooden marker (an "X") was placed at the opposite end of the runway (runway 33) to indicate that landing from that direction was unfeasible due to the power lines, the investigation found that the presence of these electrical cables was not documented in the ROTAER or via NOTAM at the time of the accident. Furthermore, while wind conditions were favorable for landing on runway 33, the pilot chose to approach runway 15, likely to avoid the known obstacle at the opposite end.
Findings
- The pilot's decision-making and flight planning were inadequate, as the approach was attempted with a tailwind on a short 700-meter runway.
- The pilot failed to maintain an adequate safety altitude to avoid the power lines during the missed approach.
- The lack of updated aeronautical information regarding the electrical lines in the ROTAER and NOTAM prevented the pilot from properly managing the risk.
- The pilot's limited experience, having received their license less than six months prior, may have contributed to the improper use of aircraft controls during the go-around.
- The physical infrastructure of the airfield, specifically the presence of the power lines and the wooden marking, played a significant role in the accident scenario.