On January 3, 2016, a Beechcraft 90 King Air (registration PP-LMM) operated by Supermercados Shibata was involved in an aviation accident near Paraty, Brazil during landing or approach. 2 people were killed. Investigators recorded the probable cause as: The official findings listed multiple contributing factors, including attention, attitude, adverse weather conditions, culture of the working group, perception, and decision-making process, while pilot forgetfulness, pilotage judgment, motivation, and… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).
A twin-engine aircraft crashed in wooded terrain near Paraty Airport after descending in instrument meteorological conditions. Both pilots were killed.
Flight Details and Accident Sequence A twin-engine aircraft departed Campo de Marte Airport at 1334 local time on a positioning flight to Paraty, with an estimated time of arrival at 1415 local time. During descent to Paraty Airport, the crew encountered instrument meteorological conditions. While on final approach under visual flight rules, the aircraft struck trees and crashed in a dense wooded area in hilly terrain a few kilometers short of the runway. The aircraft was destroyed, and both pilots were killed. ## Contributing Factors The official investigation identified several contributing factors. Attention was listed as undetermined, noting that another aircraft had successfully landed at Paraty moments before the accident, which may have focused the pilot's attention on the possibility of landing despite critical conditions. The presence of a copilot not qualified to operate the aircraft may also have affected the pilot's concentration. Attitude was identified as a contributing factor, with recurring landing attempts indicating excess self-confidence. Adverse weather conditions also contributed, as conditions were not favorable for visual flight at Paraty. The working group culture among pilots in the region was cited as a contributing factor, with competitive behavior and social recognition for operating in critical conditions weakening collective risk perception. Pilot forgetfulness was undetermined, as the landing gear was not retracted during the second launch, which may have affected climb performance and obstacle clearance. Pilotage judgment and motivation were also undetermined, with the possible decision not to retract the gear and the influence of another pilot's successful landing noted. Perception was a contributing factor, as the controlled flight into terrain indicated low situational awareness. The decision-making process also contributed, with the pilot choosing two landing attempts despite adverse weather, possibly influenced by competitive behavior and limited risk assessment. Organizational processes were undetermined, as the aircraft was operated by a group of mostly freelance pilots informally managed by a hired pilot, with no formal system for recruitment, selection, monitoring, or evaluation of professionals.
Probable cause
The official findings listed multiple contributing factors, including attention, attitude, adverse weather conditions, culture of the working group, perception, and decision-making process, while pilot forgetfulness, pilotage judgment, motivation, and organizational processes were undetermined.
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