What happened
On April 21, 1995, at approximately 17:20Q, a Neiva 821-Carajá, registration PT-VKF, crashed in the Serra de Monte Cristo region of Mato Grosso. The aircraft, operated by Agrícola Sperafico Ltda, had departed from Tangará da Serra for Pontes e Lacerda to transport bank employees.
During the flight, the aircraft deviated from its intended track of 264 degrees, instead following a heading of 246 degrees. This deviation was likely an attempt to navigate around the Chapada dos Parecis mountains to avoid deteriorating weather. While flying at a low altitude, the aircraft struck a tree approximately 15 meters tall, which led to a subsequent impact with the ground. The impact caused a fire that destroyed the aircraft, and all five occupants (one pilot and four passengers) died at the scene.
The investigation
CENIPA investigators examined the wreckage and recovered components, finding that the engines were operating at high power at the time of impact, evidenced by the position of the power levers and deformations in the propellers. The investigation confirmed that no mechanical failures or component detachments occurred during flight.
Meteorological data indicated that the area was experiencing low ceilings (between 600 and 2000 feet) and misty conditions. Although the aircraft was equipped with GPS and the pilot held an IFR rating, the departure and arrival aerodromes were not equipped for instrument operations, necessitating VFR conditions. The investigation determined that the pilot chose to continue the flight at low altitude despite the visibility restrictions.
Findings
- Adverse meteorological conditions: The weather along the route was unsuitable for VFR flight, characterized by low ceilings and reduced visibility.
- Improper judgment: The pilot failed to follow standard procedures, which would have involved ascending to a safe altitude or diverting to an alternative airport equipped for instrument approaches.
- Deficient flight planning: The flight was not adequately prepared for potential instrument flight requirements.
- Flight indiscipline: The pilot operated at a low altitude, deviating from established air traffic rules.
Safety action
- The investigating authority (SERAC 6) was tasked with conducting a special flight safety inspection of the operator.
- Safety findings from this report were to be disseminated through lectures and seminars to promote flight safety doctrine and adherence to air traffic regulations.
- Other SERAC units were instructed to alert small and medium-sized aircraft operators regarding the risks of disregarding VFR rules and the limitations of GPS usage.