Aircraft Accident at PPKG: Pilot Error During Instrument Approach (PP-LDX)

Flight Operations and Deviation from Procedure Clearance was issued for the route segment PPRF to PPKG at an approved altitude of 1,800 metres. Upon reaching the position Nazaré, the pilot descended without clearance to 1,200 metres and passed over the PPKG facility at 1,000 metres, which was 200 metres below the minimum altitude required to initiate the approach procedure as prescribed by the Directorate of Air Routes. After passing the facility, the pilot consulted the PPKG procedure and replaced it in the file. When the copilot asked whether it should be kept out, the pilot replied that it was unnecessary because he knew it by heart. ## Approach and Impact The procedure was initiated, and the aircraft returned on a heading that remained unknown to the Investigating Commission until the aircraft reached 520 metres, which was below the critical altitude of 647 metres. At that point, vertical visual contact with the runway was established, but the aircraft had already passed the critical point and was over the runway. The pilot attempted to enter the traffic visual to maintain sight of the runway, but this proved impossible on reaching final approach. The pilot began the landing return on a heading of 200 degrees and started to descend, turning on the aircraft lights. After a few moments, the copilot tried unsuccessfully to obtain visual reference by looking outside. The copilot then felt a violent impact and heard the pilot shout that he was hitting. ## Casualties and Investigation Findings Two crew members and eleven passengers were killed, and two crew members and three passengers were seriously injured. The inbound heading of 200 degrees observed by the copilot and verified by the Investigating Commission showed that the procedure carried out by the pilot did not conform to the approach chart approved by the Directorate of Air Routes. The investigation also found that when vertical visual contact with the runway was established, the aircraft was at most 40 metres from the ground, despite meteorological information from the Loide station at PPKG reporting a ceiling of 130 metres and visibility of 6 km.