What happened
On December 5, 1994, a Cessna U-206F, registration PT-JXR, departed from an unregistered airfield at Fazenda Pindoval, Mato Grosso do Sul, bound for Campo Grande. The flight, which included the pilot and three passengers, was conducted without a filed flight plan or communication with air traffic control services.
During the flight, the aircraft encountered severe weather conditions, including rain and fog that reduced visibility and obscured the Serra de Maracaju mountain range. While attempting to traverse the mountains, the aircraft struck trees and subsequently collided with the terrain. The impact resulted in the total destruction of the aircraft and the four fatalities of all occupants on board.
The investigation
The CENIPA investigation established that the aircraft was operating under Visual Flight Rules (VFR) in weather conditions that were incompatible with such operations. The investigation found that the pilot, while holding a commercial license, lacked Instrument Flight Rules (IFR) qualification. Furthermore, the aircraft was not certified for IFR flight, and its artificial horizon was inoperative at the time of the accident.
Investigators also noted significant safety irregularities regarding the cabin configuration. The rear seats had been removed to accommodate cargo, leaving two passengers traveling without seats or safety belts, positioned unsecured over the cargo. The investigation also revealed that the pilot was under significant psychological pressure to return to Campo Grande to meet a deadline for returning the borrowed aircraft, which may have influenced the decision to fly in marginal conditions.
Findings
- Adverse weather conditions: Heavy fog and rain significantly restricted visibility, making VFR flight impossible.
- Inadequate pilot qualification: The pilot attempted to fly in instrument conditions without the necessary IFR rating.
- Deficient flight planning: The flight was conducted without a flight plan, without notifying air traffic control, and with an improper assessment of the terrain and weather risks.
- Improper aircraft configuration: Two passengers were being transported without seats or restraints.
- Psychological pressure: The pilot's desire to return the aircraft on schedule, combined with pressure from passengers, likely led to a high-risk decision-making process.
- Operational indiscipline: The flight originated from an unregistered airfield and failed to adhere to standard VFR parameters.