What happened
On February 11, 1993, a Beechcraft B-55, registration PT-ONI, departed from Alfenas (SNFE) bound for Campo de Marte (SBMT). Immediately after takeoff from runway 04, the pilot executed a sharp left turn to perform a low-altitude pass over the airfield hangars. During this maneuver, the aircraft entered a steep climb with high pitch and significant bank angle. The aircraft subsequently lost aerodynamic lift, entering an uncontrolled descent. During the fall, the right wing struck electrical power lines and the left wing collided with treetops before the aircraft impacted the ground. The impact resulted in two fatalities (the pilot and one passenger) and the total destruction of the aircraft.
The investigation
CENIPA investigators examined the wreckage and found that the engines and propellers were operating at maximum power at the moment of impact, with no evidence of mechanical failure or flight control jams. The investigation established that the aircraft was in a stalled condition prior to striking the power lines. While the pilot held valid licenses and medical certificates, the investigation uncovered a pattern of risky behavior. Witnesses described the pilot as having a tendency toward "exhibitionism," frequently performing low-level passes and disregarding standard operating procedures. Furthermore, the investigation noted that the aircraft's maintenance logs were outdated, and the operator failed to provide adequate supervision to curb the pilot's documented history of flight indiscipline.
Findings
- Inadequate application of flight controls: The pilot executed a high-bank, high-pitch maneuver at low altitude and low speed, leading to an aerodynamic stall.
- Flight indiscipline: The pilot intentionally performed unauthorized low-level passes over the hangars.
- Psychological factors: The pilot exhibited exhibitionist behavior and an overconfidence that led to the disregard of safety standards.
- Deficient supervision: The operator was aware of the pilot's previous risky maneuvers but failed to implement administrative or operational measures to prevent recurrence.