What happened
On January 5, 2000, a Beechcraft BE-5SB departed Campo de Marte Airport (SBMT) at 10:30 local time, bound for Juiz de Fora (SBJF). The flight was planned as a ZULU flight, beginning under Visual Flight Rules (VFR) and transitioning to Instrument Flight Rules (IFR) at flight level 090. The aircraft was carrying the pilot and four passengers.
During the flight, the aircraft entered Instrument Meteorological Conditions (IMC) due to a passing cold front. At 11:22, radar indicated the aircraft began an intentional descent at a rate of 500 feet per minute. At 11:24, the aircraft struck Pico dos Três Estados in the Serra da Mantiqueira mountains, near Queluz, SP, at an altitude of 8,100 feet. The impact occurred at approximately 170 knots. All five fatalities were confirmed at the scene, and the aircraft was destroyed.
The investigation
CENIPA investigators established that the aircraft was flying at a level (FL090) that was lower than the minimum safety altitude required for that sector, which was FL095. The investigation revealed that the pilot had allowed the aircraft owner, who was not a licensed pilot, to occupy the left seat and effectively assume command of the flight.
Analysis of the wreckage showed the engines were operating normally at the time of impact, and the aircraft was in a cruise attitude with a slight nose-down pitch. Investigators also found that the flight plan erroneously listed four occupants when there were actually five. Furthermore, post-mortem toxicology revealed the presence of ethyl alcohol in the pilot's blood, though it was not determined to be the primary cause of the crash.
Findings
- Improper altitude selection: The pilot chose FL090, which was below the minimum safety altitude of FL095 for the area.
- Loss of situational awareness: The crew likely believed they were closer to their destination than they actually were, leading to an unauthorized and premature descent.
- Flight discipline violations: The pilot allowed an unlicensed individual to occupy the pilot's seat and influence flight decisions.
- Adverse weather: The presence of a cold front necessitated IFR operations, and the lack of visual references contributed to the controlled flight into terrain (CFIT).
- Inadequate flight planning: The flight plan did not accurately reflect the number of persons on board and failed to account for the terrain elevations in the sector.