What happened
On September 24, 1991, at approximately 13:30 local time, a Cessna 210L, registration PT-JFW, departed Campo de Marte in São Paulo, Brazil, bound for Atibaia. The flight was conducted under a special VFR (Visual Flight Rules) clearance due to deteriorating weather conditions. The pilot's ultimate destination was Belo Horizonte, but the flight was intended as an initial leg of a journey delayed by poor weather.
Immediately after takeoff from runway 12, the pilot failed to establish contact with São Paulo Approach as instructed by the Tower. Instead of following the established traffic pattern—which requires a right turn to a heading of 180 degrees—the pilot executed a left turn. This maneuver placed the aircraft on a direct heading toward the Serra da Cantare and, at an altitude of 3,900 feet, the aircraft collided with the terrain. The impact destroyed the aircraft and caused the death of the pilot.
The investigation
The CENIPA investigation examined the aircraft's airworthiness, the pilot's experience, and the meteorological conditions at the time of the accident. Investigators found that the Cessna 210L was in an airworthy condition, with all certificates and maintenance logs up to date. The engine was producing power at the moment of impact.
Regarding the pilot, while the individual held a valid private pilot license and medical certificate, they lacked instrument rating (IFR) training and had not operated this specific aircraft type for two years. The investigation also noted difficulties with cockpit ergonomics, specifically regarding the use of the VHF radio and unfamiliarity with the instrument panel layout.
Meteorological analysis revealed restricted visibility due to mist at the accident site. Furthermore, the investigation noted a lack of coordination between the Campo de Marte Tower and São Paulo Approach, as the controller was unaware the aircraft had departed, which delayed the discovery of the disappearance.
Findings
- Adverse meteorological conditions: Restricted visibility prevented the pilot from detecting the terrain obstacle.
- Deficient judgment: The pilot made an inadequate assessment of the flight parameters and terrain clearance.
- Inadequate flight planning: The pilot failed to properly prepare for the specific traffic patterns and airway requirements.
- Lack of aircraft familiarity: The pilot's limited experience with the Cessna 210L contributed to improper operational decisions, such as maintaining takeoff flap settings (10 degrees) during the flight.