What happened
On December 13, 1991, an EMB 711 aircraft, registration PT-NXL, departed from Campo Mourão, Paraná, bound for Rondonópolis, Mato Grosso. The flight, which had an estimated duration of four hours, never reached its destination. The aircraft was discovered destroyed near Fazenda Caraíba, in the municipality of Água Clara, Mato Grosso do Sul. The impact was a frontal collision with the ground in a wooded area, resulting in four fatalities.
The investigation
CENIPA's investigation revealed that the individual operating the aircraft was not a licensed pilot and did not possess a valid medical certificate. The investigation found that the pilot had previously failed a theoretical flight course and had obtained approximately 40 hours of flight time through irregular practical instruction with unqualified individuals.
Regarding the aircraft, while maintenance records appeared adequate, the EMB 711 was not certified for instrument flight (IFR), and its airworthiness certificate had expired. Investigators noted structural buckling in the wings and stabilizer, suggesting the aircraft had been subjected to loads exceeding its structural limits. Furthermore, the flight was conducted without a filed flight plan and without any communication with air traffic control services.
Findings
- Lack of Qualifications: The pilot was unlicensed, lacked necessary flight experience, and had no legal authorization to operate the aircraft.
- Inadequate Planning: The pilot failed to plan the route or check meteorological conditions, which were unfavorable for visual flight rules (VFR).
- Navigational Errors: The pilot relied almost exclusively on GPS for navigation, lacking the skills to manage the aircraft in the low-visibility, instrument conditions encountered during the flight.
- Psychological Factors: The pilot exhibited highly overconfident and impulsive behavior, disregarding aeronautical regulations and safety principles.
- Loss of Control: It is believed that the pilot entered IMC (Instrument Meteorological Conditions) and experienced spatial disorientation, leading to extreme control inputs that caused structural failure and the subsequent crash.