What happened
On November 15, 1994, at approximately 16:00 local time, an EMB-721C (registration PT-EML) departed from Blumenau, Santa Catarina, for a visual flight intended to overfly the municipality of Nova Trento. The aircraft was carrying the pilot and four passengers.
While flying at a low altitude, the aircraft passed over a bridge and subsequently encountered high-voltage power lines crossing its flight path. Witnesses observed the pilot attempting an immediate climb and acceleration to clear the obstacles. While the aircraft managed to avoid the lower, thicker wires, it struck a higher, less visible lightning protection wire. The impact caused the loss of part of the right wing, sending the aircraft into a right-hand spin. The aircraft then struck the slope of a hill in an inverted position, resulting in five fatalities.
The investigation
CENIPA's investigation established that the pilot was qualified and held valid licenses and medical certification. The aircraft's maintenance records showed that recent inspections had been completed, although the aircraft's flight hour logs were not up to date.
Investigators found that the pilot was not using appropriate aeronautical charts for navigation, relying instead on road maps which do not indicate terrain altitudes or power line locations. Furthermore, there was evidence suggesting the pilot may have been providing unauthorized flight instruction to the aircraft owner, who may have been occupying the left seat, potentially diverting the pilot's attention. The investigation also noted that the high-voltage lines lacked any visible markers or signaling to aid in obstacle avoidance.
Findings
- Improper Judgment: The pilot failed to maintain an adequate minimum altitude and misjudged the ability to clear the obstacles.
- Deficient Planning: The use of road maps instead of aeronautical charts left the crew unaware of the presence of high-voltage lines.
- Flight Indiscipline: The aircraft was operated below the minimum required altitude of 1,000 feet over a populated area.
- Unqualified Instruction: The possibility that an unqualified individual was operating the controls or receiving instruction may have contributed to the pilot's loss of situational awareness.