What happened
On December 21, 1994, a Cessna 210N, registration PT-LOD, crashed near the São Judas Tadeu farm in Itapirapuã, Goiás. The aircraft had departed from São Félix do Xingu, bound for Montes Claros de Goiás, carrying one pilot and five passengers. During the flight, witnesses observed the aircraft in an uncontrolled descent before it struck the ground at a 35-degree angle. The impact resulted in the six fatalities of all occupants and the total destruction of the aircraft. Evidence from the wreckage, including a section of the left wing found 300 meters from the main impact site, suggested the airframe suffered structural failure due to excessive aerodynamic loads.
The investigation
CENIPA's investigation established that the individual acting as the pilot possessed no formal flight training, no technical licenses, and no medical certificate of physical capacity. Furthermore, the individual lacked an IFR rating. The investigation examined the meteorological conditions, which included low ceilings, heavy cloud cover (8/8), and the presence of cumulonimbus (CB) and cumulus (CU) clouds with moderate rain, making the conditions unsuitable for visual flight rules (VFR). The investigation also noted that the aircraft had been recently acquired by one of the passengers and that there were no verifiable records regarding the adequacy or frequency of its maintenance services.
Findings
- Lack of pilot qualification: The person in command had no recorded flight experience, technical training, or legal authorization to operate the aircraft.
- Adverse weather: The presence of heavy convective activity and low visibility likely contributed to spatial disorientation of the pilot.
- Structural failure: Improper control inputs during an attempt to stabilize the aircraft likely caused aerodynamic loads exceeding the structural limits of the airframe.
- Operational failures: The flight was characterized by deficient planning, a lack of proper supervision by the aircraft owner, and a disregard for aviation regulations.
Safety action
- Local aviation authorities (SERAC) are advised to use this accident as an educational tool to emphasize the necessity of using qualified pilots in accordance with the Brazilian Aeronautical Code.
- Intensified monitoring and enforcement of general aviation activities are recommended to prevent unqualified individuals from operating aircraft.
- Owners and operators must be alerted that allowing unlicensed persons to command an aircraft can lead to criminal liability.