What happened
On April 11, 1992, at approximately 16:00, a Piper PA 28R-200, registration PT-JIQ, attempted a takeoff from an uncertified and irregular runway located at Fazenda São Geronimo in São Roque de Minas, Brazil. The pilot was attempting to transport three passengers to Piumhi.
The aircraft attempted the takeoff using runway heading 28, which involved an uphill gradient. Due to the uneven surface, presence of vegetation, and the uphill slope, the aircraft failed to accelerate sufficiently. The aircraft only achieved liftoff at the very end of the runway. Shortly after leaving the ground, the landing gear struck the treetops of a 15-meter-tall tree located only 30 meters from the runway end. The impact caused a violent deceleration and forced the aircraft into a nose-down attitude. The aircraft subsequently struck the ground and overturned, landing on its back. All four fatalities (the pilot and three passengers) occurred at the scene due to head trauma.
The investigation
CENIPA investigators examined the wreckage and the pilot's credentials, establishing several critical irregularities. The investigation found that the aircraft's engine and propeller were functioning normally prior to the impact, as evidenced by the propeller shaft shear and blade deformation, which indicated a sudden stoppage under high power.
Regarding the human factors, the investigation revealed that the pilot was medically unfit to fly. The pilot had been declared incapable of flight activities in 1984 due to amblyopia in the left eye, a condition that impaired depth perception. Furthermore, the pilot had used a fraudulent medical certificate (CCF) to maintain his private pilot license. The investigation also noted that the aircraft was not equipped with seatbelts or safety harnesses for the occupants, which contributed to the severity of the injuries.
Findings
- Overconfidence: The pilot's history of operating in critical and uncertified conditions led to an excess of confidence, causing him to underestimate the risks of the current operation.
- Improper Performance Planning: The pilot failed to account for the aircraft's performance limitations regarding the uphill runway, the uncertified surface, and the increased weight of the aircraft.
- Visual Impairment: The pilot's known visual deficiency, compounded by the sun's position at approximately 30 degrees during takeoff, likely hindered his ability to perceive the obstacle.
- Inadequate Infrastructure: The runway was uncertified, lacked proper maintenance, and contained an obstacle within the safety margin.
- Regulatory Non-compliance: The use of a fraudulent medical certificate and the operation from an uncertified strip were key contributing factors.