ASN Wikibase Occurrence # 225525
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| Date: | Monday 27 May 2019 |
| Time: | 15:18 UTC |
| Type: |  Piper PA-28-180 Cherokee Archer |
| Owner/operator: | Aeroclube de Alagoas |
| Registration: | PT-KLO |
| MSN: | 28-7405243 |
| Year of manufacture: | 1974 |
| Fatalities: | Fatalities: 3 / Occupants: 3 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Porto do Mato, Estância, Sergipe -
 Brazil
|
| Phase: | En route |
| Nature: | Private |
| Departure airport: | Salvador-Deputado Luís Eduardo Magalhães International Airport, BA (SSA/SBSV) |
| Maceió-Aeroclube de Alagoas Airport, AL (SNGS) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
The aircraft took off from the airfield Deputado Luís Eduardo Magalhães (SBSV), Salvador, BA, bound for the Aeroclube de Alagoas (SNGS), Maceió, AL, Brazil, at 13:58 UTC, under Visual Flight Rules (VFR), with one pilot and two passengers on board.
About one hour and twenty minutes after take-off, during the en-route flight, under adverse weather conditions, when the aircraft was approximately 30nm southwest of Santa Maria Aerodrome (SBAR), Aracaju, SE, there was loss of radio contact with Aracaju Approach Control (APP-AR).
In the sequence, there was detachment of components from the aircraft in flight, following the crash of the aircraft. Subsequently, the wreckage of the aircraft was located in a mangrove area in the village of Porto do Mato, Estância, SE.
Contributing factors (translated from Portuguese).
- Controls application - undetermined.
It was inferred that in an attempt to maintain control of the aircraft in adverse weather conditions in a region of turbulence, the pilot would have reacted with sudden deflections in the controls, which would have caused a high bending moment in the wings due to the exceeding of the limits for the positive load factor.
- Attention - undetermined
The extrapolation of the aircraft's speed limits may have resulted from the pilot's attention being focused on circumventing possible flight-related difficulties in deteriorating weather conditions for which he was not cleared to operate.
- Attitude - contributed.
The attitude of not considering the procedures foreseen to remain in visual flight conditions contributed to the exposure of the aircraft to a high risk of accident.
- Adverse weather conditions - contributed. The presence of meteorological phenomena on the route, identified by low cloud layer and moderate to strong precipitation with atmospheric instability, associated with the TCU cloud, interfered decisively with the aircraft's operation.
- Disorientation - undetermined.
Although there is no evidence that the aircraft has entered an abnormal attitude, it is possible that the pilot in command has engaged in a process of confusion in interpreting the aircraft's attitude when entering heavy clouds and turbulence, which may have resulted in large and sudden corrections to the flight controls.
- Flight discipline - contributed.
When entering an area with atmospheric instability and meteorological formations, the pilot failed to observe ICA 100-12/2016 Rules of the Air, which established minimum visibility and cloud distance in Visual Flight Weather Conditions (VMC). - Pilot trial - contributed. There was no adequate assessment of the parameters related to the operation of the aircraft, in particular the operational limits, for the decision to continue the flight in unfavourable weather conditions for VFR flight.
- Motivation - undetermined.
The well-known friendship with the passenger occupying the right front seat, who had pilot's licence and practice in transporting artists, in addition to the family commitments of the second passenger may have encouraged the continuation of the flight to Maceió, so that the scenario and the operational performance capacity were no longer critically analysed when faced with adverse meteorological formations.
- Perception - undetermined.
The maintenance of the flight to the initially scheduled destination suggested a possible lowering of the situational awareness level, in which the risk factors present in the scenario and which could affect the operation were not precisely taken into consideration, compromising operational safety.
- Flight planning - contributed.
The flight involving an aircraft not certified for BMI flight, on a route characterized by the presence of low clouds and with precipitations of moderate to strong intensity, associated with the TCU cloud, revealed that there was inadequacy in the pilot's preparation work for that type of operation, especially in aspects related to the route conditions.
- Little experience of the pilot - undetermined.
It is possible that the little experience in conducting a flight in circumstances characterised by atmospheric instability induced the pilot, who was in the aircraft operation, to maintain incompatible speed and to react with sudden deflections in the controls, causing a high bending moment in the wings due to the overshooting of the margins for the positive load factor ("G" load) of the aircraft.
- Decision-making process - contributed.
The decision to keep the flight to Maceió, in conditions incompatible with visual flight, showed weaknesses in the assessment of the situation, whose likely impacts on flight safety were not adequately considered. In addition, it is presumed to infer that carrying an artist who had family commitments at the destination became a relevant factor for decision making, to the detriment of relevant aspects concerning the maintenance of the safety of the operation.
- Organisational processes - undetermined.
The lack of formal processes for authorising and supervising the use of ACA aircraft away from headquarters may have contributed to the conduct of this flight under conditions inappropriate to the safety of the operation.
- Management oversight - undetermined.
The lack of mechanisms to monitor the planning of flights of the Aeroclube de Alagoas aircraft on off-host missions may have compromised the most effective monitoring of that operation, to the point of preventing the flight from taking place in weather conditions that were not favourable to VFR flight.
Accident investigation:
 |
|
Sources:
https://g1.globo.com/se/sergipe/noticia/2019/05/27/corpo-de-bombeiros-e-acionado-para-atender-acidente-envolvendo-queda-de-bimotor.ghtml
https://www.tnh1.com.br/noticia/nid/aviao-cai-com-cantor-gabriel-diniz-em-sergipe/
https://g1.globo.com/se/sergipe/noticia/2019/05/27/corpo-de-bombeiros-e-acionado-para-atender-acidente-envolvendo-queda-de-bimotor.ghtml
________________________________________
https://www.jetphotos.com/photo/6024694 (photo)
Images:
Media:
The aircraft carrying singer #gabrieldiniz was not licensed to transport passengers, but only to hold training flights. According to Brazil's National Aviation Agency, it had no irregularities. The plane belonged to Alagoas Airclub, the state Diniz was flying to. pic.twitter.com/sDSDNefoXb
— The Brazilian Report (@BrazilianReport) 27 mai 2019
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 27-May-2019 19:17 | cleberjc | Added |
| 27-May-2019 20:38 | RobertMB | Updated [Aircraft type, Cn, Departure airport, Source, Embed code] |
| 28-May-2019 04:48 | Iceman 29 | Updated [Source, Embed code] |
| 28-May-2019 04:52 | Iceman 29 | Updated [Embed code, Photo] |
| 28-May-2019 05:48 | geraldoramos | Updated [Nature, Destination airport, Narrative] |
| 28-May-2019 11:13 | RobertMB | Updated [Destination airport] |
| 28-May-2019 19:48 | Iceman 29 | Updated [Source, Embed code] |
| 29-May-2019 16:12 | cleberjc | Updated [Time, Departure airport, Embed code, Narrative] |
| 04-Nov-2020 15:40 | harro | Updated [Time, Departure airport, Destination airport, Narrative, Category, Accident report] |
| 04-Nov-2020 15:41 | harro | Updated [Narrative] |
| 04-Nov-2020 15:41 | harro | Updated [Narrative] |
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