Country
code

Minas Gerais

Crash of a Cessna 208B Grand Caravan in Belo Horizonte: 2 killed

Date & Time: Mar 6, 2024 at 1416 LT
Type of aircraft:
Operator:
Registration:
PR-AAB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Belo Horizonte - Belo Horizonte
MSN:
208B-0903
YOM:
2001
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
After takeoff from runway 31 at Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport, the single engine airplane followed a steep climb then entered a right turn when it started to lose altitude. It continued in a right turn descent configuration, apparently to reach runway 13, when it rolled to the left, impacted the ground and crashed in a grassy area located south of runway 13 threshold, bursting into flames. The passenger, a technician external to the Police Department, was injured while both pilots were killed. The airplane was totally destroyed by a post impact fire.
Crew:
Guilherme de Almeida Irber, pilot, †
José Moraes Neto, copilot. †
Passenger:
Walter Luís Martins.

Crash of a Piper PA-46-350P Malibu Mirage near Itapeva: 7 killed

Date & Time: Jan 28, 2024 at 1038 LT
Operator:
Registration:
PS-MTG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Campinas - Belo Horizonte
MSN:
46-36065
YOM:
1996
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The single engine airplane departed Campinas-Campo de Amarais-Prefeito Francisco Amaral Airport on a flight to Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport. After takeoff, the pilot continued to the east when he apparently encountered adverse weather conditions. The airplane entered an uncontrolled descent, suffered an in-flight breakup, lost a wing and eventually crashed in a prairie located less than 3 km south of Itapeva. The airplane was totally destroyed and all seven occupants were killed.

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 at 0851 LT
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
Captain / Total flying hours:
4606
Captain / Total hours on type:
1138.00
Copilot / Total flying hours:
1475
Copilot / Total hours on type:
680
Circumstances:
The airplane departed São Paulo-Congonhas Airport on an ambulance flight to Diamantina-Juscelino Kubitschek Airport, carrying two doctors and two pilots. Following an unstabilized approach, the airplane landed too far down the runway 03 and was unable to stop within the remaining distance. It overran, went down a ravine and came to rest. All four occupants evacuated with minor injuries while the aircraft was damaged beyond repair.
Probable cause:
Following a wrong approach configuration on part of the crew, it was determined that the airplane landed about 600 metres from the runway end. In such conditions, the airplane could not be stopped within the remaining distance.
The following contributing factors were identified:
- Both pilots knew each other well and often flew together, thus it is possible that they over-relied on each other during the final phase of the flight,
- This over-confidence led the crew to neglect certain parameters related to the approach manoeuvre,
- Lack of crew coordination,
- Post-accident medical examinations revealed that the pilot-in-commands' (PF) lack of reaction to the pilot monitoring's (PM) warnings, and his impaired alertness, could indicate that he was suffering from the effects of alcohol and fatigue, reducing his performances,
- The pilots' decision to continue with the landing procedure despite an unstabilized approach characterized by inadequate situational awareness,
- Poor judgment on the part of the crew who failed to take the correct decision to initiate a go-around procedure.
Final Report:

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

Date & Time: Oct 30, 2020 at 1750 LT
Type of aircraft:
Operator:
Registration:
PR-LMP
Survivors:
Yes
Schedule:
São Paulo – 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
Captain / Total flying hours:
7300
Captain / Total hours on type:
2350.00
Copilot / Total flying hours:
676
Copilot / Total hours on type:
409
Circumstances:
After touchdown on runway 29 at São Pedro Airport, the crew initiated the breaking procedure but the airplane failed to stop within the remaining distance. It overran, collided with various obstacles, went down an embankment of 10 metres and eventually came to rest 130 metres further, bursting into flames. All four occupants evacuated safely and the airplane was destroyed by a post crash fire.
Probable cause:
Studies and research showed that the low deceleration of the aircraft and the limitation of the hydraulic pressure provided by the brake system were compatible with a slippery runway scenario. Thus, one inferred that the runway was contaminated, a condition that would reduce its coefficient of friction and impair the aircraft's braking performance, making it impossible to stop within the runway limits. On account of the mirroring condition of the runway in SSDK, it is possible that the crew had some difficulty perceiving, analyzing, choosing alternatives, and acting appropriately, given a possible inadequate judgment of the aircraft's landing performance on contaminated runways.
Final Report:

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.