What happened
On July 8, 1995, at approximately 11:30 PM, a Cessna 180H, registration PT-DMZ, was performing a repositioning flight from Sorocaba, São Paulo, to Santa Rita do Sapucaí, Minas Gerais. The aircraft was intended for use in parachute jumping operations. During the flight, the crew encountered adverse meteorological conditions characterized by low clouds and continuous light rain.
Witnesses in the city of Pedra Bela observed the aircraft flying at a low altitude on two separate occasions. The aircraft subsequently collided with a hillside at an altitude of 4,350 feet in a mountainous and forested area. The impact was severe, and both the pilot and co-pilot sustained fatal injuries. The wreckage was not located until seventeen days after the accident, partly because no flight plan had been filed and no flight notification was provided to authorities.
The investigation
CENIPA's investigation established that the engine was producing power at the time of impact, as evidenced by the deformation of the propeller blades. The investigation focused on the crew's flight planning and qualifications. It was determined that the crew was navigating using a road map rather than aeronautical charts, which lacked essential terrain elevation data. Furthermore, the investigation found that both pilots were operating with expired instrument (IFR) ratings.
Findings
- Adverse weather conditions: Low clouds and rain significantly hindered visual flight rules (VFR) navigation.
- Deficient planning: The use of an inappropriate road map prevented the crew from identifying terrain elevations, leading to an altitude lower than surrounding peaks.
- Inadequate judgment: The pilot attempted to maintain visual flight in conditions that required instrument flight.
- Flight indiscipline: The crew operated with expired instrument ratings and failed to file a flight plan or notify air traffic services.
- Operational errors: The crew's lack of proper navigation tools and expired certifications contributed to the controlled flight into terrain.