What happened
On October 23, 1993, a Piper PA-28, registration PT-JGG, was returning from a mining area to Alta Floresta, Mato Grosso, under visual flight rules. During the final approach to runway 21, the pilot executed a go-around and proceeded to fly across the full length of the runway. Following this, the pilot attempted an unplanned aerobatic maneuver, specifically a slow roll.
During the maneuver, the pilot lost control of the aircraft. The aircraft struck the ground twice: the first impact occurred while the aircraft was in a wings-level attitude, and the second impact occurred while the aircraft was inverted. The force of the impacts caused an explosion and a subsequent intense fire that consumed nearly the entire airframe. The pilot sustained fatal injuries at the scene, and the aircraft was a total loss.
The investigation
CENIPA's investigation established that the aircraft's maintenance was up to date, with the last inspection having been completed approximately 72 flight hours prior to the accident. The investigation found that the aircraft was not certified for aerobatic maneuvers.
Investigators determined that the pilot had expressed intentions to perform aerobatic maneuvers to friends at the airfield earlier that day. The investigation also noted that the airfield lacked an aeronautical emergency plan and that the local fire response was neither rapid nor effective, although this was not considered a factor in the pilot's inability to survive the initial impact.
Findings
- The pilot attempted an unauthorized aerobatic maneuver without proper training or qualification.
- The aircraft was not approved for aerobatic operations according to the manufacturer's manual.
- There was a lack of flight planning and a failure to properly coordinate airspeed and altitude for the maneuver.
- The pilot's psychological state, characterized by excessive motivation due to the presence of spectators, led to an inadequate assessment of risk.
- The pilot's actions constituted a violation of air traffic and civil aviation regulations regarding aerobatic flight and operational discipline.