What happened
On February 23, 2001, a PA-28-151 departed Aeroclube de Belém Novo, destined for a private farm in Encruzilhada do Sul, Rio Grande do Sul. The flight was transporting the aircraft owner, his wife, and various supplies, including food and household goods, for the Carnival holiday.
Upon arriving at the destination, the pilot performed a low pass over the farm's landing strip. During the second approach, the aircraft was significantly misaligned with the runway axis and flying below the proper glide path. As the pilot attempted corrections on short final, the aircraft entered a vigorous right-hand turn and subsequently entered a spin. The aircraft impacted the ground vertically, 180 degrees from its original heading. The impact was followed by a post-crash fire that completely destroyed the aircraft and caused three fatalities.
The investigation
CENIPA investigators examined the aircraft, the pilot's credentials, and the characteristics of the landing site. The investigation established that the landing strip was an uncertified, clandestine field located on top of a hill. The strip featured an irregular surface of grass and mud, lacked any markings or lighting, and was flanked by dense, tall vegetation and large trees that left no margin for error.
The investigation also noted that the aircraft was likely operating at a high weight due to the large amount of cargo and supplies being transported. While the pilot held a valid Private Pilot license, she had very limited experience, with only approximately 37 total flight hours and only five hours in the PA-28-151. Furthermore, the investigation found that the landing strip's design was so deficient that local experienced pilots had previously prohibited its use.
Findings
- Improper Approach: The aircraft was on a destabilized approach, misaligned by approximately 40 degrees from the runway centerline, with the flaps retracted.
- Loss of Control: The aircraft entered a spin due to the simultaneous occurrence of a stall and a skid. The high stall speed—exacerbated by the heavy load and retracted flaps—combined with aggressive rudder inputs to correct the alignment, induced the loss of control.
- Poor Decision Making: The pilot failed to execute a missed approach (go-around) despite the unstable and dangerous approach parameters.
- Operational Risks: The flight involved operating at a critical, uncertified airfield with known hazards and high difficulty levels.
- Inexperience: The pilot's limited experience in both the aircraft type and the specific landing environment contributed to the inability to manage the complex approach.