What happened
On December 6, 2014, a Cessna U206F, registration PT-JSM, departed from Santa Maria Estancia Aerodrome in Mato Grosso do Sul, Brazil, bound for Capão Verde Aerodrome. The flight was intended to transport a pilot and one passenger. Shortly after takeoff, the aircraft entered a cloudbank, and the crew lost contact with Approach Control Campo Grande approximately seven minutes into the flight.
The aircraft subsequently crashed into the ground approximately 10 nautical miles north of the departure airfield. The impact was characterized by a high angle of downward rate, and the aircraft was destroyed. Both the pilot and the passenger sustained fatal injuries.
The investigation
CENIPA investigators examined the wreckage and the pilot's credentials, noting that while the pilot held a valid commercial license and medical certificate, his Instrument Flight Rules (IFRA) rating had been expired since April 2014. The aircraft was not certified for IFR operations.
Technical analysis of the aircraft revealed that while the engine and systems were functioning normally, the maintenance records for the airframe, engine, and propeller were outdated. Furthermore, documentation regarding structural repairs following a previous accident in 2005 was incomplete, which hindered the investigation's ability to rule out structural failure. Meteorological data suggested the presence of fog or mist at the departure site, which likely obscured visual references for the pilot.
Findings
- The pilot likely experienced spatial disorientation after losing visual references while flying into adverse weather conditions.
- The pilot's decision-making process may have been flawed, as the flight was conducted in conditions that exceeded the aircraft's visual flight rules (VFR) capabilities and the pilot's expired instrument rating.
- There was evidence of complacency regarding the risks of flying in degraded meteorological conditions.
- Latent management failures were identified, including outdated aircraft logbooks and inadequate monitoring of maintenance and repair records following a prior accident.
Safety action
CENIPA issued a safety recommendation to Brazil’s National Civil Aviation Agency (ANAC) to oversee the maintenance organization responsible for the aircraft, ensuring they possess and apply the necessary resources and competence for servicing U206F aircraft.