What happened
On October 30, 1998, at approximately 22:36 BRT, a Piper PA-31T (registration PT-WHI) was performing an instrument approach to Joinville, Brazil. The flight originated from Rio de Janeiro. During the approach, the pilot contacted Joinville radio to request weather updates, noting that the aircraft was operating under Instrument Flight Rules (IFR).
As the aircraft progressed, the controller reported deteriorating visibility, which dropped from 3,000 meters to 2,000 meters. The pilot initially reported performing the Juliet 1 procedure but corrected this to the Delta 1 (VOR/DME) procedure. Shortly after, the pilot notified the station that a missed approach was being initiated and that the aircraft would proceed toward Curitiba in the event of an aborted landing. Following this communication, no further contact was established.
Witnesses on the ground observed the aircraft flying at a low altitude over the Vigorely Beach area. The aircraft subsequently struck an elevation at approximately 460 feet, well below the Minimum Descent Altitude (MDA) required for the active procedures. The impact resulted in a post-crash fire that destroyed the aircraft. There were 3 fatalities among the occupants, including the pilot and two passengers.
The investigation
CENIPA's investigation focused on the flight profile and the pilot's decision-making during the approach. Investigators examined the aircraft's maintenance records, which showed that recent services on the autopilot and ADF had been completed, though the pilot had privately expressed concerns regarding the directional gyro.
The investigation analyzed the meteorological conditions, which were characterized by heavy mist, low ceilings (200 feet), and unstable weather patterns. Investigators also reviewed the flight procedures, noting that the pilot had deviated significantly from the prescribed missed approach profiles for both the Delta 1 and Juliet 1 procedures. The investigation also considered the pilot's psychological profile, noting a high degree of self-confidence and a known tendency to push the limits of landing minimums.
Findings
- Flight Discipline: The pilot failed to adhere to the established missed approach profiles, executing a turn that took the aircraft on a heading of approximately 090 degrees, which was inconsistent with the prescribed procedures.
- Decision Making: The pilot's excessive self-confidence and the pressure to complete the landing despite deteriorating weather led to an inadequate decision-making process.
- Meteorological Conditions: Adverse weather, including low visibility and fog, contributed to the difficulty of the approach.
- Operational Planning: A lack of adequate descent briefing and planning contributed to the deviation from standard instrument procedures.
- Terrain Clearance: The aircraft struck an obstacle at 460 feet, which was below the MDA of 500 feet (for Delta 1) or 770 feet (for Juliet 1).