What happened
On June 7, 1992, an AB-115 Aerobuero, registration PP-FGE, took off from Arthur Siqueira Airport in Bragança Paulista, Brazil, for a planned operational maintenance flight. However, shortly after departure, the pilot began performing unauthorized aerobatic maneuvers, including loops and low-level passes, over the airfield.
During these maneuvers, the pilot performed a low pass near the aeroclube hangars. After an initial pass involving a pitch-up and a right turn, a second pass resulted in the aircraft colliding with a hangar. The impact caused the aircraft to be destroyed. The pilot sustained severe injuries and later passed away three months after the accident. Two individuals on the ground sustained minor injuries.
The investigation
CENIPA's investigation established that the pilot was not qualified or experienced for aerobatic flight, and the aircraft itself was not certified for such maneuvers. While the aircraft's maintenance was up to date and weather conditions were ideal, the investigation focused on the pilot's physiological state and operational decisions.
Medical examinations revealed the pilot was in a state of "psychotic intoxication," with a blood alcohol concentration of 1.8g/l. This level of intoxication was described as a pre-comatose state, characterized by ataxia and an inability to coordinate reasoning or physical actions. Furthermore, the investigation noted a lack of oversight by the aeroclube management, which allowed an intoxicated individual to operate an aircraft under their responsibility.
Findings
- The pilot's severe intoxication rendered him incapable of performing safe flight operations.
- The pilot performed unauthorized aerobatic maneuvers without the necessary training or aircraft certification.
- Poor judgment led to an inadequate assessment of altitude and airspeed during low-level passes.
- There was a failure in operational supervision by the aeroclube regarding the use of its aircraft.
- The pilot intentionally disregarded air traffic rules and aeronautical regulations.