What happened
On June 8, 2003, a Britten-Norman BN-2A-8, registration PT-KQS, departed from São João Del Rey, MG, en route to the Porto Belo farm airstrip in Mangaratiba, RJ. The aircraft was carrying a pilot and eight passengers under VFR flight plan.
As the aircraft approached the destination, weather conditions had deteriorated into IMC. To avoid cloud layers, the pilot descended to approximately 1,500 feet. During the approach, the pilot reported a loss of power in the left engine. While attempting to manage the situation and avoid high-voltage power lines crossing the runway, the pilot decided to perform a forced landing in a nearby pasture. During the maneuver, the left wing struck a tree, causing significant damage to the left wing, landing gear, and nose. Despite the heavy impact, all nine occupants survived the accident without injuries.
The investigation
CENIPA investigators examined the aircraft's engine and fuel systems following the pilot's claim of power loss. Post-accident testing of the left engine and propeller revealed no significant mechanical or fuel-related issues that would justify the reported failure.
The investigation also focused on the pilot's decision-making process and the operational environment. Investigators noted that the pilot was flying in marginal visibility and low ceilings, which prevented a standard traffic pattern. The investigation also reviewed the organizational structure of the operator, which lacked formal oversight of flight operations, maintenance, and pilot selection.
Findings
- Improper decision-making: The pilot's decision to continue the approach into deteriorating weather was driven by excessive self-confidence and a desire to complete the mission for the aircraft owner.
- Flight discipline violations: The pilot intentionally flew below standard altitudes and breached cloud layers to maintain visual contact, violating established air traffic rules.
- Inadequate operational oversight: The operator lacked a formal system for managing flight safety, delegating all responsibilities—including maintenance and training—to a single pilot.
- Loss of control: The investigation concluded that the aircraft likely struck the tree due to maneuvering in highly restricted visibility and altitude, rather than a direct result of engine failure.
Safety action
- The operator was directed to provide Crew Resource Management (CRM) training to its pilots.
- The operator was advised to re-evaluate pilot selection criteria and seek professional assistance for flight safety management.
- Authorities were tasked with disseminating the lessons learned from this accident to flight schools and aircraft owners operating under RBHA 91.