What happened
On November 29, 2004, an AMT-200 aircraft, registration PP-EOB, was conducting a touch-and-go training flight at the Belém Novo Aerodrome (SSBN) in Rio Grande do Sul. The flight, operated by the Brigada Militar do Rio Grande do Sul, involved an instructor and a student pilot.
During the fourth takeoff of the session, the instructor reduced engine power to simulate an engine failure at a low altitude. In response to the simulated emergency, the student pilot executed a steep left-hand turn. This maneuver caused an excessive loss of altitude, resulting in the aircraft's right wing striking trees. The impact caused the aircraft to strike the ground in an inverted position, leading to a post-crash fire that completely destroyed the airframe.
The investigation
CENIPA investigators examined the flight profiles, the training environment, and the organizational culture of the operating unit. The investigation focused on the execution of the simulated emergency maneuver and the operational procedures of the GPMA (Grupamento Aéreo da Polícia Militar). The investigation also reviewed the technical specifications of the aircraft, specifically the vulnerability of the fiberglass fuel tanks to impact-induced rupture.
Findings
- The student pilot's steep turn during the simulated failure led to a critical loss of altitude.
- The instructor failed to account for a 10-knot crosswind, likely due to familiarity with stronger coastal winds.
- The operating unit's culture occasionally involved operating aircraft outside of their designed performance envelopes to meet mission objectives.
- The aircraft's fiberglass fuel tanks were susceptible to rupture upon high-energy impact, contributing to the post-crash fire.
- There were identified gaps in the standardization of pilot training and the management of operational risks within the unit.