What happened
On December 15, 1997, an Aeroboero AB-115, registration PP-GEL, departed from Marília Airport (SBML) to perform aerial photography over a nearby residential area. The flight was operated by Aeroclube de Marília and carried a pilot and a photographer in the rear nacelle.
After approximately 15 minutes of flying over the target area, the aircraft entered a 9-degree nose-down attitude, plummeting toward the ground. The aircraft collided with the garage of a residence located roughly 4 nautical miles from the runway. The impact caused the total destruction of the aircraft. The pilot sustained fatal injuries and passed away at a hospital, while the photographer escaped with minor injuries.
The investigation
CENIPA's investigation revealed that the pilot was not qualified or experienced for this specific type of aerial photography mission. The investigation also found that the aircraft, which was only certified for instructional and operational maintenance use, was being used for unauthorized commercial photography purposes.
Technical examinations of the engine identified several issues, including a failure to comply with an Airworthiness Directive (AD) regarding the carburetor float. Investigators also found partial obstructions in the intake tubes of cylinders 1 and 4 caused by carbon buildup from the fuel, as well as excessive oil sludge in the main filter, suggesting inadequate maintenance practices. Furthermore, the pilot had observed the stall warning system activating during the flight but had dismissed the warning.
Findings
- Loss of control due to a stall at low altitude and low airspeed, potentially exacerbated by atmospheric turbulence (updrafts and downdrafts).
- Inadequate pilot experience and qualification for the specific mission requirements.
- Deficient operational supervision by the Aeroclube de Marília, which assigned an unqualified pilot to a non-certified mission.
- Improper use of aircraft controls, specifically failing to use flaps during a low-speed, low-altitude maneuver.
- Maintenance deficiencies, including the failure to implement required Airworthiness Directives and improper cleaning of engine components.
- Inadequate flight planning, failing to account for the aircraft's certification limits and prevailing meteorological conditions.