What happened
On December 25, 1993, a Cessna C-210N, registration PT-OUY, departed from Vitória, Espírito Santo, with the intention of landing at Fazenda Tranquilidade in Vinhatico. Although the flight plan indicated Nanuque-MG as the destination, the actual target was the private farm.
Upon arrival at the unregistered dirt airstrip, the pilot performed a low pass to inspect the runway before initiating a landing pattern. The approach was performed too high, and the aircraft touched down on the latter third of the runway. Attempting a go-around, the pilot applied power, but there was insufficient runway remaining to safely execute the maneuver. The aircraft struck perimeter fence posts and wire, then collided with overhead power lines, which severed the right elevator. The aircraft subsequently lost control and struck the ground violently. All three fatalities occurred at the scene.
The investigation
CENIPA's investigation focused on the operational and human factors surrounding the flight. Investigators found that the pilot had been inactive from flying for six months and had not performed any flight adaptation training on this specific aircraft type prior to the mission.
The investigation also examined the role of the aircraft owner, who was a passenger on the flight. Evidence suggested the owner's presence and demanding personality may have pressured the pilot's decision-making. Furthermore, the investigation noted that the flight plan contained inaccurate destination information, a practice used to avoid scrutiny regarding the use of unregistered airstrips.
Findings
- Human Factors: The pilot's decision-making was compromised by the need to secure employment with the owner. The six-month period of inactivity led to a lack of proficiency and an inadequate assessment of the risks involved in the approach and go-around.
- Operational Factors: The landing was attempted at an unregistered, uncertified airstrip that lacked proper signaling and safety infrastructure. The pilot's approach was too high, and the decision to execute a go-around left only approximately 52 meters of runway to accelerate.
- Environmental Factors: The presence of obstacles, specifically power lines and fence posts, at the end of the runway created an insurmountable hazard once the go-around was initiated.
- Primary Cause: The failed go-around attempt due to insufficient runway length and high approach speed.