What happened
On October 10, 1996, an EMB-810C, registration PT-RGU, departed Rondonópolis, Mato Grosso, bound for Bauru, São Paulo. The flight, which included the pilot and four passengers, was conducted without a filed flight plan.
As the aircraft approached the Bauru VOR, the pilot became aware that Bauru was operating under Instrument Flight Rules (IFR) due to a cold front. Seeking visual conditions, the pilot requested a heading toward Marília, São Paulo. At the time, the Marília airfield was closed, and its NDB radio and antenna were non-operational.
While approaching the vicinity of the runway 03 threshold in Marília, the aircraft struck high-voltage power lines and a transmission tower. The impact caused the aircraft to lose control and crash into several houses within a residential complex. The impact was severe, with the aircraft striking the ground in an excessively nose-down attitude. All five occupants of the aircraft perished in the accident. Additionally, five residents of the impacted houses sustained minor injuries.
The investigation
CENIPA's investigation focused on the pilot's decision-making and the meteorological conditions. The investigation established that the pilot, while holding a Commercial Pilot license and IFR ratings, lacked sufficient experience in instrument flight, having accumulated only approximately 100 hours of IFR time over five years.
Investigators examined the aircraft's maintenance records, which were found to be adequate, and the engine performance, which showed no abnormalities; both engines were still rotating at the time of impact. The investigation also noted that the pilot had failed to plan for the flight properly, as evidenced by his inability to provide an estimated time of arrival or a proper heading for Marília when questioned by air traffic control. Furthermore, the investigation highlighted that the pilot had previously expressed a dislike for IFR operations and had attempted to avoid this specific flight due to the weather conditions.
Findings
- Spatial disorientation caused by heavy fog and reduced visibility in the Marília region.
- Inadequate flight planning, specifically the failure to prepare for IFR procedures or identify suitable alternatives.
- Improper command application resulting from the pilot's inability to maintain control during disorientation.
- Operational indiscipline, as the pilot departed under visual conditions only to enter IFR conditions without being properly prepared for the transition.
- Psychological factors, including anxiety and a tendency toward exhibitionism, which contributed to the decision to fly in adverse conditions.
- Lack of experience in instrument flight maneuvers and managing the aircraft under adverse weather.