What happened
On May 14, 2004, an EMB-721D aircraft, registration PT-ROY, departed Cuiabá, Mato Grosso, for Tangará da Serra. The flight was intended to transport two passengers to a local auction. Although the original flight plan was filed as IFR/VFR, the pilot requested to cancel the IFR portion just two minutes after takeoff, opting to maintain 2,500 ft under visual flight rules (VFR).
Due to significant departure delays, the flight was scheduled to arrive after sunset at an airfield that lacked nocturnal lighting. As the aircraft approached the destination, it encountered dense fog and a heavy stratus layer. Approximately 15 km from the destination airfield, the aircraft struck a tree in a pasture area. The impact caused the aircraft to crash 32 meters further along its path, resulting in three fatalities.
The investigation
CENIPA investigators examined the aircraft's mechanical condition and the pilot's operational decisions. The investigation confirmed that the engine and propeller were functioning normally at the time of impact and that all maintenance records were up to date. The aircraft's weight and center of gravity were within established limits.
Investigators analyzed the meteorological conditions, noting that while visibility was acceptable at the departure point, the destination was covered in thick fog. The investigation also reviewed the pilot's flight history and psychological profile, noting a reputation for high-risk maneuvers. The investigation established that the pilot had descended to 2,000 ft in a mountainous region where safety regulations required a much higher altitude to clear obstacles.
Findings
- Excessive self-confidence in the pilot's ability and the aircraft's capabilities, specifically regarding the use of GPS in poor weather.
- Improper decision-making regarding the attempt to perform a night landing at an airfield without runway lighting.
- Inadequate mission planning, which failed to account for the degraded weather and the necessity of an IFR approach.
- Flight indiscipline, characterized by the pilot's decision to fly below minimum safety altitudes and disregard meteorological minimums for VFR operations.
- Adverse meteorological conditions, specifically the presence of heavy fog that made visual navigation impossible.