What happened
On June 29, 1998, a Piper PA-30, registration PP-AFS, crashed near Rio Claro, São Paulo, during a flight intended to travel from Rio Claro (SDRK) to Santo Antônio do Leveger (SWLV). The aircraft was carrying six occupants: the pilot, the aircraft owner, and the owner's family.
Following takeoff, the aircraft entered and exited several cloud layers while performing right-hand turns. The aircraft then abruptly entered a left-hand turn, lost airspeed, and entered the clouds again. The aircraft subsequently reappeared in a descending flight path, striking a utility pole before impacting the ground in a stalled and flat attitude. The impact triggered a massive post-crash fire that consumed the aircraft. All six fatalities occurred on board, and a bystander on a bicycle sustained severe burns.
The investigation
CENIPA's investigation focused on the pilot's decision-making and the aircraft's operational state. Investigators found that the pilot was not instrument-rated and had limited experience flying multi-engine aircraft. Although the aircraft's maintenance records were up to date and the engines were functional, the aircraft was significantly overweight. The takeoff weight exceeded the maximum allowable limit by approximately 350 lbs due to full fuel tanks, six occupants, and baggage, which likely caused a rearward shift in the center of gravity (CG).
Meteorological data confirmed that visibility was extremely poor due to fog and a very low cloud ceiling of approximately 100 meters, making visual flight rules (VFR) impossible. Furthermore, the investigation revealed that the pilot had been attempting to depart for four days but had been denied authorization by a temporary control tower due to the weather. The pilot proceeded with the takeoff only after the temporary tower was deactivated.
Findings
- Improper Flight Conditions: The pilot executed a takeoff in weather conditions that were prohibited for VFR operations at a non-instrument-rated aerodrome.
- Human Factors and Pressure: The pilot, prone to nervousness in difficult situations, succumbed to psychological pressure from the aircraft owner, who was described as an authoritative and impatient individual.
- Inadequate Training: The pilot lacked the necessary instrument rating to navigate the cloud layers encountered during the flight.
- Operational Errors: The pilot failed to maintain adequate airspeed, leading to a stall and loss of control at a low altitude.
- Weight and Balance: The aircraft was operated significantly above its maximum takeoff weight, with a rearward CG shift that likely compromised controllability.
- Flight Discipline: The pilot ignored warnings from other pilots and proceeded despite known meteorological restrictions.