What happened
On December 27, 1993, an EMB 201A aircraft, registration PT-GTF, was performing a ferry flight from Primavera do Leste to Campo Verde, Mato Grosso. Upon arriving at the destination aerodrome, the pilot performed an unauthorized low pass over the runway. Following this maneuver, the pilot executed an aggressive pitch-up and a left-hand turn at the far end of the runway. During this maneuver, the aircraft entered a stall, causing it to collide with the ground. The impact was followed by a post-crash fire that completely destroyed the aircraft. The pilot sustained fatal injuries at the scene.
The investigation
CENIPA's investigation established that the aircraft was in good airworthiness condition, with all required inspections and maintenance up to date. The investigation focused on the pilot's flight maneuvers and decision-making. It was determined that the pilot did not follow standard visual traffic patterns for landing. Instead, the pilot intentionally bypassed established procedures to perform a low pass. The investigation also noted that the pilot's experience level was limited, with fewer than 500 total flight hours. Due to the intensity of the post-impact fire, which melted the wreckage, certain physical tests of the debris could not be performed.
Findings
- Inappropriate Flight Maneuvers: The pilot executed an excessive pitch-up and a sharp turn without properly evaluating the aircraft's airspeed, altitude, or the environmental temperature.
- Flight Indiscipline: The pilot intentionally disregarded standard visual traffic patterns to perform the low pass.
and the pilot's lack of experience in managing the aircraft's energy during such maneuvers.
- Psychological Factors: The presence of known individuals on the ground, including the pilot's son, likely created excessive motivation to perform the maneuver, which reduced the pilot's situational awareness.
- Deficient Supervision: There was a lack of adequate administrative oversight regarding the hiring of an inexperienced pilot for the mission.