5 fatalities

2017-01-19: Beechcraft 90 King Air (PR-SOM) — Hotel Emiliano — Paraty, Brazil

Paraty, BrazilLanding (descent or approach)

On January 19, 2017, a Beechcraft 90 King Air (registration PR-SOM) operated by Hotel Emiliano was involved in an aviation accident near Paraty, Brazil during landing or approach. 5 people were killed. Investigators recorded the probable cause as: Contributing factors: - Adverse meteorological conditions - a contributor; - Decision-making process - a contributor; - Disorientation - undetermined; - Emotional state - undetermined; - Tasks characteristics - undetermined; - Visual illusions - undetermined;… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781192028Data APIEditorial standards

A twin-engine aircraft crashed into the sea near Paraty during a second approach in heavy rain, killing all five occupants including a Supreme Court justice. The official investigation cited weather, pilot decision-making, and disorientation as contributing factors.

Accident Sequence

The twin-engine aircraft departed Campo de Marte Airport at 1301LT bound for Paraty, a distance of about 200 km with an expected flight time of half an hour. Approach to Paraty Airport was made in poor weather conditions with heavy rain reducing visibility to 1,500 meters. The pilot lost visual contact with the airport and initiated a go-around. A few minutes later, while completing a second approach, the pilot lost visual references with the environment and lost control of the aircraft. The aircraft crashed into the sea near the island of Rasa, approximately 4 km short of runway 28. Rescuers arrived quickly and found a passenger alive but could not enter the cabin, which was submerged. The aircraft quickly sank to a depth of a few meters. All five occupants were killed.

Victims

Among the deceased were Carlos Alberto, founder of Hotel Emiliano, and Supreme Court Justice Teori Zavascki, who had a central role overseeing a massive corruption investigation about the Brazilian oil group Petrobras.

Official Findings

The probable cause as determined by investigators includes contributing factors: adverse meteorological conditions (a contributor), decision-making process (a contributor), disorientation (undetermined), emotional state (undetermined), tasks characteristics (undetermined), visual illusions (undetermined), and work-group culture (a contributor). The horizontal visibility of 1,500 meters was below the minimum required for VFR landing and take-off operations at the SDTK aerodrome, which only permitted VFR operations. The pilot's two attempts to land in unsafe conditions indicated inadequate evaluation of minimum conditions. Low visibility and low height over water likely led to spatial disorientation. Emotional stress and anxiety may have influenced the pilot's decision to attempt another landing. The operational culture in Paraty valued pilots who operated under adverse conditions, potentially leading to self-imposed pressure and reduced safety margins. Vestibular and visual illusions likely caused the pilot to misperceive bank angle and altitude.