What happened
On September 9, 2002, at approximately 17:30 local time, a Piper PA-28R, registration PT-DTN, crashed into terrain in the Taipas neighborhood of São Paulo, Brazil. The aircraft had departed from Campo de Marte (SBMT) for Marília (SBML) with four people on board.
During the flight, the aircraft was operating under a Special VFR flight plan due to prevailing misty conditions. Radar data from São Paulo Approach (APP-SP) indicated that the aircraft was not maintaining its assigned altitude and was deviating from the established visual corridors. Witnesses reported seeing the aircraft flying at an extremely low altitude near surrounding hills shortly before a loud impact was heard. The aircraft struck trees and the terrain in a landing configuration, with the landing gear and flaps extended. The impact resulted in three fatalities among the passengers and left the pilot with serious injuries.
The investigation
CENIPA's investigation focused on the pilot's proficiency, the meteorological conditions, and the flight planning. The investigation established that while the pilot held a valid Commercial Pilot license, he lacked sufficient experience to operate in the prevailing instrument meteorological conditions (IMC). The pilot had not flown to São Paulo in approximately one year and had very limited recent IFR training, having not flown under actual IMC conditions for eight months.
Investigators examined the aircraft's maintenance records and found the PA-28R to be in good condition, with all inspections up to date and the engine functioning normally at the time of impact. The investigation also noted that the aircraft was operating above its planned weight, though this was not a contributing factor to the crash. The investigation highlighted that the pilot's decision-making was influenced by high levels of anxiety regarding the weather and the pressure of the mission.
Findings
- Adverse meteorological conditions: The presence of mist and low cloud bases significantly restricted visibility, making visual flight operations unsafe.
- Deficient flight planning and judgment: The pilot failed to properly analyze the deteriorating weather along the route and attempted to maintain VFR flight in conditions that required IFR proficiency.
- Inadequate pilot experience: The pilot lacked the necessary IFR training and recent experience in the local terrain to safely navigate the visual corridors under the prevailing conditions.
- Human factors: The pilot's excessive self-confidence and potential physiological stressors, such as visual illusions or disorientation, contributed to the deviation from established flight corridors.
- Operational errors: The aircraft was observed flying outside the prescribed lateral and vertical limits of the visual corridors, and the pilot was operating the aircraft in a landing configuration during the en route phase.