Date:	Friday 22 May 2009
Time:	20:53
Type:	Beechcraft B300 King Air 350
Owner/operator:	Santa Coloma Investimentos e Participações Ltda.
Registration:	PR-MOZ
MSN:	FL-237
Year of manufacture:	1999
Total airframe hrs:	3556 hours
Engine model:	Pratt & Whitney Canada PT6A-60A
Fatalities:	Fatalities: 14 / Occupants: 14
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	Porto Seguro-Terravista Golf Club Airport, BA -   Brazil
Phase:	Approach
Nature:	Executive
Departure airport:	São Paulo-Congonhas Airport, SP (CGH/SBSP)
Destination airport:	Porto Seguro-Terravista Golf Club Airport, BA (SBTV)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Beechcraft 350 Super King Air was destroyed in an accident at the Terravista Golf Club Airport, Bahia, Brazil. All 14 on board were killed.
The crew took off from São Paulo-Congonhas Airport, SP (CGH) at 18:31, with the Terravista Golf Club Airport (SBTV) as destination.
During the approach for landing at 20:53, amid a heavy rain, the aircraft crashed into a tree about 900 yards from runway 15. After the first collision, the aircraft flew for 700 meters, eventually colliding against other trees and then into the ground

Contributing factors:
1 Human Factor
1.1 Medical Aspect
Nothing to report.
1.2 Psychological Aspect
1.2.1 Individual information
1.2.1.1 Attitude - contributed
The failure of the crew to comply with the prescribed standards and procedures contributed to the occurrence of this accident.
1.2.1.2 Motivation - contributed
High motivation for landing. The pilot did not observe all the critical aspects surrounding the flight situation and proceeded to land under unfavourable conditions.
1.2.1.3 Perception - contributed
The crew, faced with adverse conditions, presented loss of situational awareness, when they did not present the precise perception of the conditions affecting the flight, which may have been influenced by the high motivation to land, hindering the critical analysis.
1.2.1.4 Decision making process - contributed
There was a loss of critical analysis of the situation in this flight, when in the judgment the crew decided to continue the flight to a landing in an uncertain environment.
1.2.2 Psychosocial information
Nothing to report.
1.2.3 Organisational information
1.2.3.1 Organisational Processes - contributed to
The organization did not have a system to monitor the commander's operational performance in order to identify and correct existing malfunctions.
1.3 Operational Aspect
1.3.1 Adverse weather conditions - contributed
Based on the dialogues from the CVR it was possible to verify that, during the descent and while flying over the Terravista Aerodrome, the crew was able to perceive that the field was not operating in visual conditions. Nevertheless, the crew proceeded with the visual procedure.
1.3.2 Deviation from navigation - contributed
The crew requested the cancellation of the instrument flight plan, without in fact being in visual condition and using on-board GPS equipment to carry out an "improvised" IFR procedure during the traffic circuit in the Terravista Airfield.
1) A different visual traffic circuit than that established in the air traffic rules has been established:
2) Excessive speed was used, contrary to the Aircraft Flight Manual;
3) The wind leg was performed at the bow 360, 30 degrees offset to the right of the ideal bow;
4) The wind leg was performed in the NE sector instead of the SW sector, contrary to what was predicted in the ROTAER; and
5) No altitude was maintained in the leg with the wind, having reached 600 feet.
1.3.3 Cabin coordination - contributed
The crew has lost situational awareness of the vertical location (descent slope). The co-pilot possibly trusted and accepted the commander's decisions without contesting them. There was complacency from the co-pilot, probably influenced by his little flying experience, enhanced by the absence of CRM training.
Decisions were made only by the commander based on his own perception, assuming the risk of proceeding to landing without having obtained visual contact with the runway. This fact evidences flaws in the decision-making process.
1.3.4 Trial of pilotage - contributed
The dialogue conducted between the pilots suggests that they obtained visual contact with the track, momentarily, during the performance of the "improvised" GPS procedure. It is observed the failure in this aspect, considering that it was not taken into account that the aerodrome operated below the minimum (VFR), which made it impossible, in fact, the success in concluding the final approach.
1.3.5 Flight planning - contributed
All the necessary meteorological information for planning the flight to the destination was available in the AIS Room before Congonhas took off. Based on a proper analysis of the available meteorological information and taking into account risk management, the crew should have followed the planning established in the flight plan and made the landing at Porto Seguro, instead of driving it to the Terravista Aerodrome, which operated below the minimum (VFR).
1.3.6 Management supervision - undetermined
The pilot played a decisive role in the operational and administrative supervision of the aircraft, as he was

23:00 UTC / 20:00 local time:
METAR 222300Z 20006KT 5000 -RA FEW012 BKN015 BKN050 22/22 Q1020.

CENIPA

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