What happened
On January 27, 2000, a F-33A Bonanza, registration PT-LVW, departed from the Santa Maria aerodrome near Campo Grande, Brazil, bound for Paranaíba. The flight, which was intended to be a short trip, was delayed by one hour due to a depleted aircraft battery.
Shortly after takeoff, witnesses observed the aircraft performing extremely low-altitude maneuvers, flying at approximately 6 meters (20 feet) over a residential neighborhood in Campo Grande. This flight pattern violated standard visual flight rules (VFR) regarding minimum altitudes over urban areas. Approximately 30 minutes after departure, the aircraft was spotted flying at low altitude near the Estância “JB” in Ribas do Rio Pardo. The aircraft subsequently impacted the ground at a 30-degree nose-down angle with wings level, causing the aircraft to disintegrate upon impact. The pilot sustained fatal injuries due to polytrauma.
The investigation
CENIPA investigators examined the wreckage and the pilot's history to determine the cause of the accident. Technical analysis of the engine and propeller indicated that the Teledyne Continental IO-520-BB-18 engine was producing power at the moment of impact. There was no evidence of fuel exhaustion, as the aircraft had been fueled with 72 liters of fuel, which was sufficient for the intended trip. Furthermore, inspections of the tail surfaces showed no signs of control surface jamming.
The investigation also reviewed the pilot's medical and psychological status. Records from the week preceding the accident showed that the pilot was experiencing significant emotional instability and stress, as noted by both cardiologists and immunologists. Additionally, the investigation noted that the pilot had relatively little experience in this specific aircraft type, with only 50 flight hours recorded on the model.
Findings
- Psychological instability of the pilot influenced the decision-making process, leading to the unsafe decision to fly at such low altitudes.
- Deficient flight planning and the decision to maintain a low-altitude profile increased operational risk and reduced the time available to manage any potential in-flight issues.
- Flight indiscipline was present, as the pilot operated the aircraft significantly below the required altitude for VFR over populated areas.
- The pilot lacked sufficient experience in the F-33A Bonanza to potentially manage the flight dynamics during the low-altitude maneuvers.