What happened
On April 26, 2012, an EMB-712 aircraft, registration PT-NUH, departed from Sorocaba (SDCO) for a flight training mission toward Itanhaém (SDIM). The crew consisted of a flight instructor and a student pilot. During the descent, the aircraft encountered deteriorating weather conditions and entered Instrument Meteorological Conditions (IMC). While navigating the mountainous terrain near the Serra do Mar, the aircraft struck a hill near the Santos Air Base (SBST). The impact resulted in two fatalities, as both occupants died at the scene. The aircraft sustained substantial damage.
The investigation
CENIPA's investigation focused on the meteorological environment and the decision-making process of the crew. Investigators found that a cold front was approaching the region, bringing heavy rain, thunderstorms, and low ceilings. Radar imagery confirmed high reflectivity, indicating active thunderstorms. The investigation also noted that the EMB-712 was not certified for IFR (Instrument Flight Rules) operations and lacked onboard weather radar.
Furthermore, the investigation examined the organizational structure of the flight school, noting a lack of flight operations supervision and a centralized decision-making process that placed the entire burden of flight safety on the individual instructor. While the aircraft's airworthiness certificate was valid, the maintenance logs for the airframe, engine, and propeller were found to be outdated.
Findings
- Inadequate decision-making: The instructor made a flawed decision to depart and continue the flight despite receiving warnings about deteriorating weather and high winds.
- Loss of situational awareness: The crew likely experienced spatial disorientation after entering IMC, potentially due to a loss of focus on instruments while searching for external visual references.
- Operational risks: The flight was conducted in adverse meteorological conditions that were unsuitable for a VFR-only aircraft.
- Organizational deficiencies: The flight school lacked adequate operational oversight, and the instructor's motivation to accumulate flight hours may have led to an underestimation of the risks involved.