What happened
On September 26, 1999, a CAP-10 aircraft, registration PT-XGV, departed from the Caxias do Sul aerodrome (SBCX) for an aerobatic check flight. The crew consisted of an experienced instructor and a pilot undergoing final evaluation. Shortly after takeoff, the instructor radioed that they were performing a simulated engine failure training maneuver.
At an altitude of approximately 500 feet, the aircraft entered a steep right-hand turn with a high bank angle and a high rate of descent. The aircraft subsequently struck the ground, impacting a residential yard and colliding with a house wall. The impact destroyed the aircraft and caused the fatal deaths of both occupants.
The investigation
CENIPA's investigation focused on the sequence of events following the simulated failure. The investigation confirmed that the engine was functioning normally at the time of impact and the aircraft was in airworthy condition. Meteorological conditions were favorable for visual flight.
Investigators examined the pilot's physiological state, noting that the pilot had experienced significant sleep deprivation—having slept less than four hours the night before—and had consumed alcohol the previous evening. Furthermore, the investigation looked into the regulatory status of the flight, finding that the aerobatic course being conducted was not authorized by the Civil Aviation Department (DAC) and that the aircraft's registration category (TPP) was inappropriate for instructional use.
Findings
- Human Factors: The pilot's decision-making and physiological state were critical factors. Fatigue, caused by lack of sleep and recent alcohol consumption, impaired the pilot's reflexes, perception, and attention. Additionally, the pilot's limited experience in the CAP-10 (only 10 hours) led to a failure in judgment; the pilot attempted a high-bank turn to return to the runway, which induced an aerodynamic stall.
- Operational Deficiencies: The training program lacked an approved syllabus and clear safety parameters for maneuvers. The instructor's decision to perform a simulated failure during a check flight surprised the pilot, contributing to the loss of control.
- Regulatory Non-compliance: The aircraft was being used for instruction despite being registered under a category that did not permit it, and the aerobatic course was being conducted without proper authorization from the DAC.