What happened
On May 18, 1997, at approximately 16:55, a mid-air collision occurred in Lages, Santa Catarina, during celebrations for the anniversary of the local Aeroclube. The event involved two aircraft: a Cessna 310 Q, registration PT-IJA, and a Cessuna 182 P, registration PT-ISM.
The PT-ISM was in the process of taking off to perform a parachuting operation. Simultaneously, the PT-IJA was performing a low-altitude pass over the crowd on the right side of the runway. Following the low pass, the pilot of the PT-IJA executed an aggressive recovery maneuver. During this pull-up, the right engine of the PT-IJA struck the tail cone of the PT-ISM at approximately 500 feet.
The impact caused the PT-ISM to disintegrate into six parts, ejecting its occupants. The PT-IJA lost its right engine and part of its right wing, rendering it uncontrollable and causing it to impact the ground in a steep dive. The collision resulted in the deaths of all eight occupants of the PT-IJA and all four occupants of the PT-ISM. Additionally, one resident on the ground was killed when an occupant of the PT-ISM struck her home.
The investigation
CENIPA's investigation focused on the operational and human factors surrounding the event. The investigation established that while both pilots held valid commercial licenses and medical certificates, neither was qualified for the specific maneuvers being performed (low-altitude passes and parachuting operations).
Investigators examined the lack of communication between the aircraft, noting that while the local radio station informed the circuit of the PT-IJA's intentions, the pilot of the PT-IJA failed to establish bilateral contact with the departing PT-ISM. The investigation also looked into the organizational aspects of the event, noting that the organizing committee had conducted a briefing that the involved pilots did not attend, and no dedicated safety or coordination officer had been appointed for the aerial activities.
Findings
- Human Factors: The pilot of the PT-IJA exhibited psychological traits including excessive self-confidence and an impulsive temperament, which contributed to the decision to perform unauthorized maneuvers. The pilot also operated the PT-IJA with eight occupants, exceeding the aircraft's capacity.
- Operational Factors: There was a significant lack of flight discipline, as the low-altitude pass was performed without authorization. The event planning was deficient, as the organizers failed to provide adequate supervision or a dedicated safety coordinator.
- Environmental Factors: The position of the sun may have caused glare, potentially reducing the pilot's ability to identify the other aircraft during the high-G recovery maneuver.
- Primary Cause: The aggressive recovery maneuver performed by the PT-IJA following an unauthorized low-altitude pass led to the collision.