What happened
On December 29, 1996, a Cessna 182 P Skylane, registration PT-ILN, departed from Canarana, Mato Grosso, bound for Votuporanga, São Paulo. The aircraft was carrying one pilot and five passengers, including three children. The flight was conducted without a flight plan or communication with air traffic control.
As the aircraft approached Rio Verde, Goiás, it was observed flying at a low altitude beneath a dense cloud layer during moderate rain. Witnesses near the mountainous region reported hearing the engine before seeing the aircraft emerge from the clouds in a steep, high-speed dive. The aircraft struck the ground vertically, resulting in the total destruction of the airframe and the deaths of all six occupants.
The investigation
CENIPA investigators examined the wreckage and found that the airframe had been subjected to G-loads exceeding its structural design limits. Specifically, a portion of the right wing and the elevator detached in flight prior to impact. Evidence suggested the engine was operational at the time of impact and fuel was present in the tanks.
The investigation focused on the pilot's decision-making and the aircraft's operational configuration. It was noted that the aircraft was not certified for IFR (Instrument Flight Rules) operations. Furthermore, the aircraft was carrying two passengers beyond its maximum seating capacity, which caused the center of gravity to shift rearward.
Findings
- Spatial Disorientation: The investigation concluded that the pilot likely entered IMC (Instrument Meteorological Conditions) and experienced spatial disorientation, leading to an abnormal attitude.
- Passenger Pressure: The pilot faced significant pressure from the passengers, including a company director, to complete the flight for holiday travel purposes, despite being advised by another pilot not to depart due to poor weather.
- Overloading: The presence of extra passengers, including children aged three, five, and twelve, resulted in an aft center of gravity shift, which contributed to the loss of control.
- Lack of Qualification: While the pilot held a valid commercial license, he was not rated for IFR flight, and the aircraft was not equipped or certified for instrument operations.
- Regulatory Non-compliance: The flight was operated without a flight plan and without any contact with air traffic control services.
Safety action
CENIPA issued recommendations to the company utilizing the aircraft (Frigorífico Frican Ltda) to implement safety training for management to prevent undue pressure on flight crews. The company was also directed to implement procedures to ensure aircraft operations remain within manufacturer-specified parameters, specifically regarding maximum passenger capacity.