What happened
On January 1, 1998, a Cessna 210-L, registration PT-KCR, departed from Londrina (SBLO) on a Visual Flight Rules (VFR) flight plan destined for Bacacheri (SBBI) in Curitiba. The aircraft was carrying a pilot and one passenger. During the flight, the pilot contacted Curitiba Approach and was informed that the destination airport was operating under instrument conditions.
Unable to land at the primary destination, the pilot decided to divert to the alternative airport, Ponta Grossa (SBGS). While en route, the pilot reported that they were unable to establish contact with Ponta Grossa Radio and intended to perform a spiral descent to check for visual conditions beneath the cloud layer, as terrain was visible. Local residents observed the aircraft flying at a very low altitude shortly before it collided with the side of a hill in the Serra de Itaiacacia region, approximately 50 feet above the summit. The impact resulted in two fatalities and the total destruction of the aircraft.
The investigation
CENIPA's investigation focused on the flight conditions and the pilot's decision-making process. The investigation confirmed that the aircraft was in airworthy condition, with all maintenance records and engine inspections up to date. The pilot was highly experienced, holding a Commercial Pilot license and possessing significant flight hours.
Investigators examined the meteorological data, which revealed that weather conditions were unfavorable for VFR flight, with a cloud ceiling of approximately 600 feet. The investigation also reviewed the pilot's operational decisions, specifically the choice to depart for a destination known to be under instrument procedures and the subsequent attempt to navigate under the cloud base in hilly terrain. The investigation found that the pilot's flight path violated established separation standards between the aircraft, the clouds, and the terrain.
Findings
- Improper decision-making: The pilot's high level of self-confidence led to the decision to fly VFR into an area where the destination was operating under instrument rules.
- Inadequate flight planning: The flight plan did not account for the instrument conditions at the primary destination and failed to prepare for the risks of navigating hilly terrain under cloud cover.
- Poor judgment and flight discipline: The pilot intentionally flew below the cloud base, violating the required 1,000-foot separation from clouds as established by aeronautical regulations.
- Adverse meteorological conditions: Low ceilings and restricted visibility significantly hindered the pilot's ability to maintain visual references to the terrain.