What happened
On October 23, 2001, a group of aircraft took off from the Piracicaba Aerodrome in São Paulo, Brazil, to perform a formation flight in celebration of "Aviator's Day." While the group initially consisted of nine aircraft, only five successfully joined the formation. The flight was led by an Embraer E-810C (PT-EAX).
During a left-hand turn, the 7ECA (PT-OEM), which was not equipped with a radio, crossed the formation and struck the underside of the right wing of a Cessna C-1-85A (PT-BQM). In an attempt to correct the aircraft's position following the impact, the pilot of the PT-BQM executed an abrupt left maneuver, causing the aircraft to collide with the right propeller of the lead E-810C.
The impact severed the tip of the PT-BQM's right wing, sending the aircraft into a right-hand spin. The PT-BQM subsequently crashed into a two-story building, causing significant damage to the structure. The passenger in the PT-BQM, who was unseated and unrestrained in the rear of the aircraft, was ejected upon impact and died instantly. The pilot of the PT-BQM succumbed to injuries two days later. The lead aircraft, PT-EAX, sustained heavy damage to its engine and propeller but managed to perform an emergency single-engine landing. The PT-OEM sustained only minor damage.
The investigation
The CENIPA investigation focused on the sequence of collisions and the operational environment. Forensic analysis of paint transfers confirmed that the PT-OEM struck the PT-BQM first, followed by the collision between the PT-BQM and the PT-EAX.
Investigators examined the qualifications of the pilots, noting that none of the involved crews possessed the necessary training, experience, or specific certification required for formation flying. The investigation also looked into the technical configuration of the aircraft, finding that the PT-BQM was configured for parachute jumps and lacked a rear seat and seatbelts for the passenger. Furthermore, the investigation noted a lack of communication, as the lead pilot was unaware that the PT-OEM lacked radio capabilities.
Findings
- Lack of training and experience: The pilots involved did not have the required training, experience, or specific authorization to perform formation maneuvers.
- Inadequate planning: No specific pre-flight briefing was conducted regarding the formation sequence or emergency procedures.
- Operational errors: The formation consisted of aircraft with vastly different performance characteristics and geometries, and the pilots failed to maintain proper separation.
- Inadequate supervision: The flight schools involved permitted the use of aircraft by unqualified pilots for this type of operation.
- Safety deficiencies: The PT-BQM was operating without a seat or seatbelt for the passenger, which potentially compromised the pilot's ability to control the aircraft during the spin.
- Organizational culture: The investigation identified a culture of excessive confidence and improvisation, driven by a competitive environment that encouraged impulsive decision-making without proper safety considerations.