Country
code

Minas Gerais

Crash of a Beechcraft C90A King Air in Caratinga: 5 killed

Date & Time: Nov 5, 2021 at 1515 LT
Type of aircraft:
Operator:
Registration:
PT-ONJ
Survivors:
No
Schedule:
Goiânia – Caratinga
MSN:
LJ-1078
YOM:
1984
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
16352
Copilot / Total flying hours:
2768
Circumstances:
The twin engine airplane departed Goiânia-Santa Genoveva Airport on a taxi flight to Caratinga, carrying three passengers and two pilots. On final approach to Caratinga-Ubaporanga Airport in VFR conditions, the airplane collided with a lightning rod located on the top of a high-voltage pylon. Upon impact, the left engine was torn off and the airplane stalled before crashing in a river bed located about 4,1 km short of runway 02. The airplane was destroyed by impact forces and all five occupants were killed, among them the Brazilian singer Marília Mendonça aged 26.
Probable cause:
The following factors were identified:
- Attention – undetermined.
It was found the possibility that the PT-ONJ aircraft crew had their attention (focused vision) on the runway at the expense of maintaining proper separation with the terrain on a visual approach.
- Piloting judgment – a contributor.
Regarding the approach to landing profile, there was an inadequate assessment of the aircraft's operating parameters, since the downwind leg was elongated by a significantly greater distance than that expected for a "Category B" aircraft in landing procedures under VFR.
- Memory – undetermined.
It is likely that, based on the experience of ten years of operation in a company governed by the RBAC 121, the PIC procedural memory has influenced the decisions made concerning the conduct of the aircraft. The habit of performing long final approaches in another type of operation may have activated his procedural memory, involving cognitive activities and motor skills, making the actions automated in relation to the profile performed in the accident.
- Flight planning – undetermined.
A possible non-use of the available aeronautical charts (CAP 9453 and WAC 3189), which were intended to meet the needs of visual flight, may have contributed to low situational awareness about the characteristics of the relief around the SNCT Aerodrome and the presence of the power grid that interfered with the aircraft's landing approach.
Final Report:

Crash of a Learjet 35A in Belo Horizonte: 1 killed

Date & Time: Apr 20, 2021 at 1430 LT
Type of aircraft:
Registration:
PR-MLA
Flight Type:
Survivors:
Yes
Schedule:
Belo Horizonte - Belo Horizonte
MSN:
35-072
YOM:
1976
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew departed Belo Horizonte-Pampulha Airport for a local test flight. After landing on runway 13, the crew encountered difficulties and the aircraft was unable to stop within the remaining distance. It overran, went through the perimeter fence (striking concrete poles) and came to rest against trees, broken in two. The copilot aged 76 was killed while both other occupants were injured.

Crash of a Learjet 31A in Diamantina

Date & Time: Jan 2, 2021
Type of aircraft:
Operator:
Registration:
PP-BBV
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Diamantina
MSN:
31-113
YOM:
1995
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed São Paulo-Congonhas Airport on an ambulance flight to Diamantina, carrying two doctors and two pilots. After landing on runway 03, the aircraft was unable to stop within the remaining distance, overran, went down a ravine and came to rest. All four occupants evacuated with minor injuries while the aircraft was damaged beyond repair.

Crash of a Embraer EMB-500 Phenom 100 in São Pedro

Date & Time: Oct 30, 2020 at 1815 LT
Type of aircraft:
Operator:
Registration:
PR-LMP
Survivors:
Yes
Schedule:
Belo Horizonte – São Pedro
MSN:
500-00094
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While approaching São Pedro Airport by night, the aircraft crashed in a wooded area short of the airfield, bursting into flames. All four occupants evacuated the cabin and the aircraft was totally destroyed by a post crash fire.

Crash of a Gulfstream G200 in Belo Horizonte

Date & Time: Sep 7, 2020 at 1826 LT
Type of aircraft:
Operator:
Registration:
PR-AUR
Flight Type:
Survivors:
Yes
Schedule:
Belo Horizonte - Belo Horizonte
MSN:
140
YOM:
2006
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Belo Horizonte-Pampulha Airport, consisting of touch-and-go maneuvers. After landing on runway 13, the pilot-in-command decided to abort the takeoff. Unable to stop within the remaining distance, the aircraft overran, lost its landing gear and came to rest near a concrete block. All three occupants evacuated, among them the captain was slightly injured.

Crash of a Cessna 525 CitationJet M2 in Fazenda Fortaleza de Santa Terezinha: 4 killed

Date & Time: Nov 26, 2018 at 0830 LT
Type of aircraft:
Operator:
Registration:
PP-OEG
Survivors:
No
Schedule:
Belo Horizonte - Fazenda Fortaleza de Santa Terezinha
MSN:
525-0849
YOM:
2014
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11000
Captain / Total hours on type:
522.00
Circumstances:
The twin engine airplane was completing a flight from Belo Horizonte-Pampulha-Carlos Drummond de Andrade to the Fortaleza de Santa Terezinha Farm (Fazenda Fortaleza de Santa Terezinha) located in Várzea da Palma, Jequitaí, Minas Gerais. On board were three passengers and one pilot. On final approach to runway 20, during the last segment, the airplane collided with a metallic water irrigation system. The pilot initiated a go around procedure when he lost control of the airplane that veered to the left, impacted the ground and crashed in a field located to the left of the runway, about 600 metres from the initial impact, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all four occupants were killed, among them Mr. Adolfo Geo, owner of the Brazilian group ARG Ltd active in food, oil and construction. He was accompanied by his wife Margarida Janete Geo.
Probable cause:
The following factors were identified:
- Airport infrastructure – a contributor.
It was found that the irrigation pivot, at the point where the collision took place, was impairing the gauge of the approach surface as described in Ordinance 957/GC3, of 09JUL2015, which provided for restrictions on objects projected into the airspace that could adversely affect the safety or regularity of air operations.
- Piloting judgment – a contributor.
The final approach was carried out below the ideal approach ramp, allowing the collision against the pivot, located in the alignment of the runway.
- Perception – undetermined.
It is possible that the PIC, when approaching for the landing, did not notice the irrigation pivot and, therefore, collided with the obstacle.
- Flight planning – a contributor.
There was no prior coordination with the farm employees, in a timely manner so that the irrigation pivot could be repositioned to a safe location in relation to the flight trajectory on the final landing approach.
Final Report:

Crash of a Cessna 650 Citation VII in Guarda-Mor: 4 killed

Date & Time: Nov 10, 2015 at 1904 LT
Type of aircraft:
Operator:
Registration:
PT-WQH
Flight Phase:
Survivors:
No
Schedule:
Brasília – São Paulo
MSN:
650-7083
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
13143
Copilot / Total flying hours:
2527
Copilot / Total hours on type:
1633
Circumstances:
The aircraft took off from the Presidente Juscelino Kubitschek (SBBR) Aerodrome, Brasília - DF, to the Congonhas Aerodrome (SBSP), São Paulo - SP, at 2039 (UTC), to carry out a personnel transportation flight with two crewmembers and two passengers on board. During the cockpit preparation procedure, the crew members commented about the operation of the Pitch Trim System. The first flight of the day, that occurred in the morning, was from São Paulo to Brasilia and with no abnormalities. About thirty minutes after take-off from Brasília, still during the climb, near the FL370, the cabin voice recorder recorded a characteristic sound of the aircraft’s horizontal stabilizer moving. Then, the aircraft made a downward trajectory with high speed and a big rate of descent until the impact against the ground. The aircraft was destroyed. All occupants perished at the site, among them Lúcio Flávio de Oliveira and Marco Antonio Rossi, two Directors of Banco Brasdesco.
Probable cause:
Contributing factors:
- Control skills – undetermined
It is possible that, after inadvertent movement of the horizontal stabilizer, the crewmembers did not operate on the control switches of the secondary pitch trim system, since no other warning sound (Clacker) was recorded on the CVR recordings. The action prevised in the emergency procedures Pitch Trim Runaway or Failure, item 3, regarding trimming of the aircraft through the secondary system, possibly, was not performed. The performance of the crew may have been restricted only to the elevator control on the aircraft controls or to the control of the stabilizer associated with the primary trimming mode.
- Attitude – undetermined
The decision to make the flight without the proper functioning of the primary pitch trim and autopilot system may have been the result of the pilot's self-confidence because of the successful previous flight under similar operating conditions. Considering the hypothesis that the updated Shutdown Checklist, which should incorporate the Stabilizer Trim Backdrive Monitor - TEST, was not performed after the precrash flight, one could consider that there was a lack of adhesion to the aircraft operating procedures. Such an attitude could be associated with the pilot's self-confidence about the aircraft's operating routine, whose acquired experience could have given him the habit of ignoring some of the procedures deemed less important during the flight completion phase.
- Crew Resource Management – a contributor
Throughout the flight, there was an absence of verbalization and communication of the actions on the checklist. Similarly, in the face of the emergency situation of the horizontal stabilizer (Pitch Trim Runaway or Failure), no statements were identified regarding the actions required to manage this situation among the crew. These characteristics denote inefficiency in the use of human resources available for the aircraft operation.
- Training – undetermined
It is possible that the absence of a periodic training in simulator, especially the emergency Pitch Trim Runway or Failure, has affected the performance of the crew, as far as the CVR did not record statements related to the actions required by the abnormal condition experienced.
- Organizational culture – undetermined
The operator did not usually properly fill out the PT-WQH flight logbook. This condition evidenced the existence of informal rules regarding the monitoring of the operational conditions of the aircraft. In this context, it is possible that the history of failures related to the pitch trim system has not been registered.
- Piloting judgment – undetermined
Moments prior to takeoff, it was recorded in the CVR speeches related to the flight without the autopilot, possibly related to a failure or inoperativeness of the primary pitch trim system. The takeoff with a possible failure in the pitch trim system of the aircraft, showed an inadequate assessment of the risks involved in the operation under those conditions.
- Aircraft maintenance – undetermined
It was not possible to establish a link between the maintenance services performed on the aircraft in September 2015 and the events that resulted in the accident occurred on 10NOV2015. However, it was not ruled out that an incomplete crash survey was carried out in the pitch trim system of the aircraft, due to the lack of detail of the service orders.
- Decision-making process – a contributor
The sounds related to the test positions of the Rotary Test Switch have not been recorded in the CVR recording, so it is possible to conclude that the Warning Systems - Check item of the Cockpit Preparation Checklist has not been performed. The decision to perform the flight without the complete execution of all items of the Cockpit Preparation Checklist, prevented the correct verification of the primary longitudinal Trim system of the aircraft and reflected an inadequate judgment about the risks involved in that operation.
- Interpersonal relationship – undetermined
According to the CVR data, there was a possible rush of the crew to take-off, even though it was verified that the aircraft's pitch trim system did not work properly. It was not possible to determine if this rush was motivated by passengers’ pressure or self-imposed by the pilot.
- Support systems – undetermined
It is possible that the Pilots' Abbreviated Checklist - NORMAL PROCEDURES, aboard the aircraft, was outdated, without the incorporation of the Stabilizer Trim Backdrive Monitor - TEST procedure in the Shutdown Checklist. The possible completion of Shutdown Checklist with outdated procedures would have hampered the manufacturer's suggested verification for identification of abnormalities in the aircraft's pitch trim system.
- Managerial oversight – undetermined
The records and control of the operational check flights, both by the maintenance shop and by the operator, prevised in documentation issued by the manufacturer (SB650- 27-53 and ASL650-55-04) were not performed in an adequate manner, indicating possible weaknesses in the supervision of the maintenance activities.
Final Report:

Crash of an Embraer C-95BM Bandeirante in Lagoa Santa

Date & Time: Jul 27, 2015
Type of aircraft:
Operator:
Registration:
2326
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lagoa Santa - Lagoa Santa
MSN:
110443
YOM:
1984
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was conducting a training mission at Lagoa Santa AFB, consisting of touch-and-go maneuvers. During the takeoff roll, the pilot-in-command pulled on the control column to initiate the rotation but the aircraft did not respond. It went out of control, veered off runway to the right, struck an embankment, lost its undercarriage and slid for few dozen metres before coming to rest in a grassy area. All three occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
It is believed that the accident was a consequence of a wrong takeoff configuration as the crew did not set the flaps properly.

Crash of a Beechcraft C90GTi King Air in Belo Horizonte: 3 killed

Date & Time: Jun 7, 2015 at 1525 LT
Type of aircraft:
Operator:
Registration:
PR-AVG
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Belo Horizonte – Setubinha
MSN:
LJ-1891
YOM:
2008
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine airplane departed Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport on a flight to Setubinha-Fazenda Sequóia Airfield, carrying one employee of the company and two pilots. Prior to takeoff, the captain informed the copilot he wanted to perform an 'American' takeoff with full engine power followed by a steep climb. After liftoff, the crew raised the landing gear then continued over the runway at low height until the end of the terrain to reach a maximum speed, then initiated a steep climb at 90°. The aircraft reached the altitude of 1,700 feet in 15 seconds then stalled and entered an uncontrolled descent. It dove into the ground and crashed in a vertical attitude into a houses located in a residential area some 800 metres from the airport. The aircraft was destroyed by impact forces and a post crash fire and all three occupants were killed. One people on the ground was slightly injured.
Probable cause:
Loss of control after the crew initiated aerobatic maneuvers at low altitude.
Final Report:

Crash of a Beechcraft B200 Super King Air in Juiz de Fora: 8 killed

Date & Time: Jul 28, 2012 at 0745 LT
Operator:
Registration:
PR-DOC
Survivors:
No
Schedule:
Belo Horizonte - Juiz de Fora
MSN:
BY-51
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
14170
Captain / Total hours on type:
2170.00
Copilot / Total flying hours:
730
Copilot / Total hours on type:
415
Aircraft flight hours:
385
Aircraft flight cycles:
305
Circumstances:
The twin engine aircraft departed Belo Horizonte-Pampulha Airport at 0700LT on a flight to Juiz de Fora, carrying six passengers and two pilots. In contact with Juiz de Fora Radio, the crew learned that the weather conditions at the aerodrome were below the IFR minima due to mist, and decided to maintain the route towards the destination and perform a non-precision RNAV (GNSS) IFR approach for landing on runway 03. During the final approach, the aircraft collided first with obstacles and then with the ground, at a distance of 245 meters from the runway 03 threshold, and exploded on impact. The aircraft was totally destroyed and all 8 occupants were killed, among them both President and Vice-President of the Vilmas Alimentos Group.
Probable cause:
The following factors were identified:
- The pilot may have displayed a complacent attitude, both in relation to the operation of the aircraft in general and to the need to accommodate his employers’ demands for arriving in SBJF. It is also possible to infer a posture of excessive self-confidence and confidence in the aircraft, in spite of the elements which signaled the risks inherent to the situation.
- It is possible that the different levels of experience of the two pilots, as well as the copilot’s personal features (besides being timid, he showed an excessive respect for the captain), may have resulted in a failure of communication between the crewmembers.
- It is possible that the captain’s leadership style and the copilot’s personal features resulted in lack of assertive attitudes on the part of the crew, hindering the exchange of adequate information, generating a faulty perception in relation to all the important elements of the environment, even with the aircraft alerts functioning in a perfect manner.
- The meteorological conditions in SBJF were below the minima for IFR operations on account of mist, with a ceiling at 100ft.
- The crew did not inform Juiz de Fora Radio about their passage of the MDA and, even without visual contact with the runway, deliberately continued in their descent, not complying with the prescriptions of the items 10.4 and 15.4 of the ICA 100-12 (Rules of the Air and Air Traffic Services).
- The crew judged that it would be possible to continue descending after the MDA, even without having the runway in sight.
Final Report: