What happened
On June 29, 2001, a PA 28-180 operated by Aeroclube de Santiago departed from São Gabriel, RS, for a planned training flight to Santiago, RS. Although the flight was intended to be a solo navigation training mission, the flight plan was significantly altered during the mission. The aircraft diverted from its route to fly over the city of Jaguari, RS, to perform sightseeing and low-altitude maneuvers over the pilot's relatives' property.
During these maneuvers, the pilot executed a high-bank turn at a very low altitude. The left wing of the aircraft struck a fence post, causing the aircraft to lose control and impact the ground. The impact resulted in one fatality among the passengers, while the two crew members and the remaining passenger sustained minor injuries. The aircraft sustained severe damage and was considered a total loss.
The investigation
CENIPA's investigation revealed a series of regulatory and operational deviations. The pilot in command had transferred control of the aircraft to another pilot who was flying with an expired type rating (CHT). The investigation found that the flight crew lacked the necessary experience for the specific maneuvers being performed, particularly regarding the aircraft's performance limits during low-altitude turns.
Investigators also noted that the aircraft's manual was unavailable both on board and in the flying club's library, preventing the pilots from accurately assessing stall speeds and maneuverability limits. Furthermore, the investigation highlighted a lack of oversight within the flying club, noting the absence of an Aircraft Accident Prevention Program (PPAA) and weak supervision from the club's instructional and safety directorates.
Findings
- Excessive confidence and exhibitionism by the pilot, who was known for performing unauthorized low-altitude maneuvers.
- Inadequate flight experience for the specific maneuvers being executed, specifically regarding high-bank turns at low altitudes.
- Flight indiscipline, including the transfer of command to a pilot with an expired rating and performing unauthorized maneuvers.
- Lack of situational awareness and safety culture within the organization, characterized by a culture of complacency among the crew.
- Deficient aircraft performance knowledge due to the absence of the aircraft manual.
- Ineffective command application during the turn, which brought the aircraft to a critical state near a stall.