What happened
On January 28, 1999, an EMB 721C Sertanejo, registered as PT-EOY, departed from Ponta Grossa Airport (SSZW) for a visual flight to Campo Mourão (SSKM). At the time of departure, the region was covered in heavy fog, resulting in significantly restricted visibility and low ceilings.
Shortly after takeoff, while executing a right turn from runway 25, the aircraft disappeared into the fog. Moments later, the aircraft struck the terrain approximately 1,000 meters to the right of the runway. The impact, which occurred at a 45-degree nose-down angle with a 90-degree right wing low attitude, resulted in the fatal injury of the pilot and the total destruction of the aircraft.
The investigation
CENIPA investigators examined the wreckage and the pilot's operational history. Technical analysis of the engine and propeller by the Institute of Aeronautics and Space (IAE/CTA) found no mechanical anomalies that could have contributed to the accident. The investigation also reviewed the pilot's credentials, noting that while his medical certificate was valid, his commercial pilot license and technical training certificate (CHT) had expired. Furthermore, the pilot lacked the necessary instrument flight rules (IFR) rating required for the weather conditions present.
Investigators considered two primary hypotheses for the loss of control: a sudden medical event, such as a non-fatal heart attack, or spatial disorientation. The investigation concluded that spatial disorientation was the most probable cause, as the pilot likely prioritized maintaining visual contact with the ground, leading to an uncontrolled bank during the turn in the fog.
Findings
- Psychological factors: The pilot exhibited an impulsive temperament and excessive confidence in his abilities. His decision to fly was heavily influenced by high levels of anxiety and financial pressure related to his agricultural aviation business.
- Operational errors: The pilot engaged in flight indiscipline by operating under conditions that required an IFR rating for which he was not qualified. He also utilized a flawed planning strategy, assuming he could clear the fog by climbing, despite the prevailing weather.
- Meteorological conditions: Heavy fog and restricted visibility prevented safe visual flight operations.
- Organizational culture: The pilot operated with a high degree of autonomy, establishing a personal flight culture that disregarded standard aeronautical regulations and air traffic rules.