What happened
On September 24, 1991, an EMB 810 C operated by Madeireira Barra Grande Ltda departed Bacacheri (SBBI) for a local test flight following significant engine maintenance, including the replacement of cylinders, pistons, and valves. Although the original flight plan specified IFR conditions at FL 060, the pilot requested to maintain VMC at 5,0-00 ft after takeoff.
During the return leg toward Curitiba (SBCT), the pilot reported being in "occasionally IFR" conditions. Despite warnings from Curitiba Approach regarding natural obstacles in the sector, the aircraft continued its flight path. While descending to 4,500 ft, the aircraft struck the Pico do Marumbi in the Serra do Mar region. The impact occurred while the aircraft was in straight and level flight. The collision resulted in two fatalities, including the pilot and one passenger, and the total loss of the aircraft.
The investigation
The CENIPA investigation examined the pilot's flight history, the aircraft's maintenance records, and the meteorological conditions at the time of the accident. The investigation found that the aircraft had recently undergone a 100-hour inspection on the day of the accident and that all maintenance services were adequate.
Investigators analyzed the pilot's decision-making process, noting that while the pilot was typically regarded as a responsible and careful professional, his conduct during this flight deviated from his standard pattern. The investigation also looked into the meteorological state of the Serra do Mar, which was heavily obscured by clouds, preventing visual navigation.
Findings
- Adverse meteorological conditions: Extensive cloud cover over the Serra do Mar prevented the pilot from maintaining visual contact with the terrain.
- Deficient judgment: The pilot, despite his familiarity with the region, incorrectly assessed his distance from the airfield during the descent.
- Human factors: The pilot's psychological state and decision-making were likely influenced by the presence of a passenger, a fellow pilot seeking flight experience, which may have contributed to a departure from his usual cautious conduct.
- Inadequate planning: The initial flight planning for a test flight under IFR conditions was deemed insufficient for the task at hand.
- Operational deviation: The pilot attempted to operate under VFR rules while actually encountering IFR conditions, ignoring controller warnings regarding terrain.