What happened
On November 28, 1999, at approximately 17:30 local time, a Cessna 172 (registration PT-DIN) departed from Amarais Aerodrome (SDAM) in Campinas, Brazil, for a planned 15-minute scenic flight. The aircraft was carrying the pilot and three passengers.
Shortly after takeoff from runway 16, at an altitude of approximately 250 feet, the aircraft began to descend while maintaining a nose-up attitude. The aircraft then entered a left-hand turn. As the turn reached approximately 90 degrees, the aircraft stalled and entered a spin, impacting the ground in a nearby coffee plantation. The impact was followed by a post-crash fire that destroyed most of the airframe. All four occupants perished in the accident.
The investigation
CENIPA investigators examined the wreckage and the engine, finding that the engine was producing no power at the time of impact. While the engine components (crankshaft, connecting rods, and valves) appeared intact, investigators considered the possibility of a magneto failure. Witnesses reported a chronic, undocumented issue where the magneto selector switch failed to select both magnetos, even when appearing to do so.
Additionally, investigators looked into reports of a malfunctioning pilot seat locking mechanism, which had previously caused the seat to slide backward. Such a movement could have inadvertently induced a nose-up attitude. The investigation also noted that while the aircraft's maintenance logs were up to date, there was a local habit of reporting mechanical discrepancies verbally to mechanics without formal documentation in the aircraft's flight logs.
Findings
- Adverse weather conditions: The aircraft departed with a 25-knot crosswind from the right, significantly exceeding the manufacturer's maximum allowable crosswind limit of 15 knots.
- Improper flight planning and execution: The pilot elected to perform a passenger flight for which he was not qualified, as his license was for private use only and did not permit remunerated passenger transport.
- Pilot error and loss of control: The pilot's attempt to turn back toward the runway at a low altitude, combined with the high-drag nose-up attitude and the wind shifting to a tailwind component during the turn, led to the stall and spin.
- Regulatory non-compliance: The pilot was operating with an expired medical certificate and lacked the necessary qualifications for the specific type of operation being conducted.
- Inadequate supervision: The flight club failed to implement effective oversight to ensure pilots were properly rated for the operations they were performing and that all mechanical discrepancies were formally recorded.