Country
code

Rio de Janeiro

Crash of a Beechcraft C90GT King Air off Paraty: 5 killed

Date & Time: Jan 19, 2017 at 1244 LT
Type of aircraft:
Operator:
Registration:
PR-SOM
Survivors:
No
Schedule:
Campo de Marte - Paraty
MSN:
LJ-1809
YOM:
2007
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7464
Captain / Total hours on type:
2924.00
Circumstances:
The twin engine aircraft departed Campo de Marte Airport at 1301LT bound for Paraty. With a distance of about 200 km, the flight should take half an hour. The approach to Paraty Airport was completed in poor weather conditions with heavy rain falls reducing the visibility to 1,500 metres. While descending to Paraty, the pilot lost visual contact with the airport and initiated a go-around. Few minutes later, while completing a second approach, he lost visual references with the environement then lost control of the aircraft that crashed in the sea near the island of Rasa, about 4 km short of runway 28. Quickly on site, rescuers found a passenger alive but it was impossible to enter the cabin that was submerged. The aircraft quickly sank by a depth of few metres and all five occupants were killed, among them Carlos Alberto, founder of Hotel Emiliano and the Supreme Court Justice Teori Zavascki who had a central role overseeing a massive corruption investigation about the Brazilian oil Group Petrobras.
Probable cause:
Contributing factors:
- Adverse meteorological conditions - a contributor
At the moment of the impact of the aircraft, there was rain with rainfall potential of 25mm/h, covering the Paraty Bay region, and the horizontal visibility was 1,500m. Such horizontal visibility was below the minimum required for VFR landing and take-off operations. Since the SDTK aerodrome allowed only operations under VFR flight rules, the weather conditions proved to be impeding the operation within the required minimum safety limits.
- Decision-making process - a contributor
The weather conditions present in SDTK resulted in visibility restrictions that were impeding flight under VFR rules. In this context, the accomplishment of two attempts to approach and land procedures denoted an inadequate evaluation of the minimum conditions required for the operation at the Aerodrome.
- Disorientation - undetermined
The conditions of low visibility, of low height curve on the water, added to the pilot stress and also to the conditions of the wreckage, which did not show any fault that could have compromised the performance and/or controllability of the aircraft, indicate that the pilot most likely had a spatial disorientation that caused the loss of control of the aircraft.
- Emotional state - undetermined
Through the analysis of voice, speech and language parameters, variations in the emotional state of the pilot were identified that showed evidence of stress in the final moments of the flight. The pilot's high level of anxiety may have influenced his decision to make another attempt of landing even under adverse weather conditions and may have contributed to his disorientation.
- Tasks characteristics - undetermined
The operations in Paraty, RJ, demanded that pilots adapt to the routine of the operators, which was characteristic of the executive aviation. In addition, among operators, possibly because of the lack of minimum operational requirements in SDTK, the pilots who landed even in adverse weather conditions were recognized and valued by the others. Although there were no indications of external pressure on the part of the operator, these characteristics present in the operation in Paraty, RJ, may have favored the pilot's self-imposed pressure, leading him to operate with reduced safety margins.
- Visual illusions - undetermined
The flight conditions faced by the pilot favored the occurrence of the vestibular illusion due to the excess of "G" and the visual illusion of homogeneous terrain. Such illusions probably had, consequently, the pilot's sense that the bank angle was decreasing and that he was at a height above the real. These sensations may have led the pilot to erroneously correct the conditions he was experiencing. Thus, the great bank angle and the downward movement, observed at the moment of the impact of the aircraft, are probably a consequence of the phenomena of illusions.
- Work-group culture - a contributor
Among the members of the pilot group that performed routine flights to the region of Paraty, RJ, there was a culture of recognition and appreciation of those operating under adverse conditions, to the detriment of the requirements established for the VFR operation. These shared values promoted the adherence to informal practices and interfered in the perception and the adequate analysis of the risks present in the operation in SDTK.
Final Report:

Crash of a Beechcraft C90GTi King Air in Paraty: 2 killed

Date & Time: Jan 3, 2016 at 1430 LT
Type of aircraft:
Operator:
Registration:
PP-LMM
Flight Type:
Survivors:
No
Site:
Schedule:
Campo de Marte - Paraty
MSN:
LJ-1866
YOM:
2008
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
801
Captain / Total hours on type:
319.00
Copilot / Total flying hours:
159
Circumstances:
The twin engine aircraft departed Campo de Marte Airport at 1334LT on a positioning flight to Paraty, with an ETA at 1415LT. While descending to Paraty Airport, the crew encountered instrument meteorological conditions. On final, while approaching under VFR mode, the aircraft impacted trees and crashed in a dense wooded area located in hilly terrain few km short of runway. The aircraft was destroyed and both pilots were killed.
Probable cause:
Contributing factors:
- Attention - undetermined
Moments before the accident, another aircraft successfully completed the landing at the Paraty aerodrome. It is possible that the pilot's attention was focused on this information, which indicated the possibility of landing, despite the critical conditions faced, leading him to take high risks to make the landing in critical conditions.
Also, the presence of a copilot not qualified to operate the aircraft may have influenced the pilot's cognitive processes, causing deconcentration or deviation of attention from the pilot.
- Attitude - contributed
Recurring attempts to make the landing indicated an excess of self-confidence on the part of the pilot, leading him to continue the flight to the Paraty aerodrome, even in adverse weather conditions.
The bold operational profile of the pilot, his past experience and the rules and values ​​adopted informally in the group of pilots are possible factors that influenced the development of this attitude of excessive self-confidence.
- Adverse weather conditions - contributed
On the day of the accident, the weather conditions were not favorable for visual flight at the Paraty aerodrome.
- Culture of the working group - contributed
Among the pilots who operated in the Paraty region, competitive behavior had been installed, valued by the social recognition attributed to those who managed to operate in critical conditions. Above all, landing under conditions adverse weather conditions in the region was considered a manifestation of proficiency and professional competence. The values ​​shared by that group of pilots favored the weakening of the collective perception about the present operational risks. The presence of other pilots who were also trying to land in the region on the day of the occurrence, as well as the landing made by one of these aircraft, moments before the accident, and also the accomplishment of two failed attempts of the PP-LMM aircraft, translates clear evidence of that behavior.
- Pilot forgetfulness - undetermined
The fact that the landing gear was not retracted during the second launch in the air indicated a failure, fueled by the possible forgetfulness of the crew, to perform the planned procedure. Maintaining the landing gear in the lowered position affected the aircraft's performance during the ascent, which may have contributed to the aircraft not reaching the height required to clear obstacles.
- Pilotage Judgment - undetermined
The possible decision not to retract the landing gear during the launch affected the aircraft's performance during the climb, which may have contributed to the aircraft not reaching the height necessary to clear the obstacles.
- Motivation - undetermined
The successful landing by the pilot of another aircraft, even under unfavorable conditions, may have increased the motivation of the pilot of the PP-LMM aircraft to complete the landing, in order to demonstrate his proficiency and professional competence.
- Perception - contributed
The occurrence of a collision with the ground, in controlled flight, indicated that the crew had a low level of situational awareness at the time of the occurrence. This inaccurate perception of the circumstances of the flight made it impossible to adopt the possible measures that could prevent the collision.
- Decision making process - contributed
The pilot chose to make two landing attempts at the Paraty aerodrome, despite adverse weather conditions, indicating an inaccurate assessment of the risks involved in the operation. This evaluation process may have been adversely affected by the competition behavior installed among the pilots. In this context, it is possible that the pilot based his decision only on the successful landing of another aircraft, a fact that limited his scope of evaluation.
- Organizational processes - undetermined
The PP-LMM aircraft was operated by a group of pilots, mostly composed of freelance professionals, who were informally managed by a hired pilot. Therefore, there was no formal system used by the operator to recruit, select, monitor and evaluate the performance of professionals. The failures related to the management of this process, possibly, caused inadequacies in the selection of pilots, in the crew scale, in untimely activations and, as in the case in question, in the choice of crew member not qualified to exercise function on board.
Final Report:

Crash of a Piper PA-46R-350T Matrix off Jacarepaguá: 2 killed

Date & Time: Aug 21, 2012 at 1935 LT
Operator:
Registration:
PT-FEM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Jacarepaguá – Campo de Marte
MSN:
46-92158
YOM:
2010
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after a night takeoff from Jacarepaguá Airport, the single engine aircraft entered an uncontrolled descent and crashed in the sea. Few debris were found several days later. The pilot's body was found on September 4 on a beach in Barra de Tijuca. The wreckage and the copilot's body were never found. It was reported that the crew did not activate the transponder after takeoff and did not contact ATC for unknown reasons.

Crash of a Piper PA-31-310 Navajo C off Jacarepaguá

Date & Time: Jul 24, 2012 at 1610 LT
Type of aircraft:
Operator:
Registration:
PT-WOT
Survivors:
Yes
Schedule:
Jacarepaguá - Jacarepaguá
MSN:
31-7912021
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was engaged in a survey flight off the State of Rio de Janeiro and departed Jacarepaguá-Roberto Marinho Airport in the afternoon. While returning to his base, the pilot encountered problems and decided to ditch the aircraft. The airplane came to rest few hundred metres offshore. All three occupants were rescued and the aircraft sank.

Crash of an Embraer EMB-121A1 Xingu II off Angra dos Reis: 3 killed

Date & Time: Jul 12, 2012 at 1715 LT
Type of aircraft:
Registration:
PT-MAB
Survivors:
No
Schedule:
Belo Horizonte - Angra dos Reis
MSN:
121-007
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2735
Captain / Total hours on type:
2065.00
Copilot / Total flying hours:
1820
Copilot / Total hours on type:
1283
Circumstances:
The twin engine aircraft departed Belo Horizonte-Pampulha Airport on a charter flight to Angra dos Reis, carrying one passenger and two pilots. On approach to Angra dos Reis, the crew encountered poor weather conditions with a cold front approaching the area. On short final, while completing a right turn at low height, the right wing struck the water surface and the aircraft crashed in the sea, some 500 metres offshore. The wreckage was found 3 km from the airport. All three occupants were killed and aircraft was destroyed. Visibility was low at the time of the accident with heavy rain falls, low clouds and turbulences. The passenger was the local representative of the Mercedes Benz Group.
Probable cause:
The collision with water and the subsequent accident was the consequence of the decision of the crew to continue the approach at low altitude to maintain a visual contact with the ground. At the time of the accident, the visibility was limited and weather conditions were marginal.
Final Report:

Crash of a Learjet 55C Longhorn in Rio de Janeiro

Date & Time: Aug 12, 2010 at 0926 LT
Type of aircraft:
Operator:
Registration:
PT-LXO
Flight Type:
Survivors:
Yes
Schedule:
Rio de Janeiro - Rio de Janeiro
MSN:
55C-135
YOM:
1988
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17000
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
2800
Copilot / Total hours on type:
49
Circumstances:
The aircraft departed Rio de Janeiro-Santos Dumont Airport on a positioning flight to Rio de Janeiro-Galeão-Antonio Carlos Jobim Airport with three crew members on board. Two minutes after takeoff, while in initial climb, the electrical system of the aircraft suffered a voltage power loss. Several instruments lost their functionality such as TCAS, altimeters and airspeed indicator. In good weather conditions, the captain decided to return to Santos Dumont Airport but did not declare any emergency. After being cleared to descend to 3,000 feet, the crew lost all radio communications. On final approach to runway 02R, most of the instruments failed but the crew continued the approach. The aircraft passed over the runway threshold with an excessive speed of 25 knots and after touchdown, the crew started the braking procedure but the spoilers and the reversers could not be activated. Unable to stop within the remaining distance, the aircraft overran and came to rest in the Guanabara Bay. All three crew members escaped uninjured while the aircraft was damaged repair.
Probable cause:
An error in the assembly was detected in the left generator, which interfered with the D+ terminal signal sent to the voltage regulator. Due to a voltage drop, some of the instruments lost their functionality. The following contributing factors were identified:
- The crew did not follow the emergency procedures;
- The crew decided to return to land at Santos Dumont Airport without considering that the runway length was less than the length required for an emergency landing;
- The speed of the aircraft while passing over the runway threshold was 25 knots above the reference speed;
- The pilots were unable to engage the spoilers or the thrust reversers;
- Wrong attitude from the captain;
- Overconfidence of the crew;
- Emotional load due to an emergency situation;
- Poor assessment of the situation due to high stress associated with decreased situational awareness;
- Poor crew coordination;
- Lack of crew resource management;
- Poor judgment;
- Lack of procedures on the part of the operator.
Final Report:

Crash of an Embraer EMB-500 Phenom 100 in Angra dos Reis

Date & Time: Oct 12, 2009 at 1310 LT
Type of aircraft:
Registration:
PP-AFM
Flight Type:
Survivors:
Yes
Schedule:
Campo de Marte – Angra dos Reis
MSN:
500-00049
YOM:
2009
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
39.00
Copilot / Total flying hours:
1400
Copilot / Total hours on type:
39
Aircraft flight hours:
14
Circumstances:
Following an uneventful flight from Campo de Marte, the crew initiated the approach to runway 10 which is 961 metres long. After touchdown, the crew started the braking procedure but the aircraft skidded on runway and cartwheeled. It overran, lost its both main gears and came to rest six metres further. Both pilots escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- The crew considered the operation at Angra dos Reis Airport as unsafe, but operated the aircraft at that airport several times due to pressures from the aircraft's owner,
- The landing was completed with a tailwind component and a high aircraft weight, without considering the possibility to use runway 28, which demonstrated a poor assessment of the existing landing conditions,
- The relative short landing distance available, less than one km,
- The possible pressure exerted by the owner to carry out the flights, as well as the need to maintain the job or the professional image, may have contributed to the complacency behavior of the crew on the issues that lead to the operation of aircraft under conditions below acceptable safety standards,
- Poor flight planning,
- The relative low experience of the crew on this type of aircraft.
Final Report:

Crash of a Let L-410UVP-E20 near Rio Bonito: 19 killed

Date & Time: Mar 31, 2006 at 1739 LT
Type of aircraft:
Operator:
Registration:
PT-FSE
Flight Phase:
Survivors:
No
Site:
Schedule:
Macaé – Rio de Janeiro
MSN:
91 25 32
YOM:
1991
Flight number:
TIM6865
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
10000
Captain / Total hours on type:
39.00
Copilot / Total flying hours:
5220
Copilot / Total hours on type:
1719
Aircraft flight hours:
2739
Aircraft flight cycles:
3960
Circumstances:
The twin engine aircraft departed Macaé Airport at 1719LT on a flight to Rio de Janeiro-Santos Dumont Airport with 17 passengers and two pilots on board. Few minutes later, the copilot cancelled the IFR flight plan and continued under VFR mode at an altitude of 4,500 feet. Approaching São Pedro da Aldeia, the copilot was cleared to descend to 2,000 feet to avoid poor weather conditions. Later, while approaching Saquarema, the crew initiated a left turn to avoid clouds when shortly later, at an altitude of 1,920 feet, the aircraft struck the Pedra Bonita Peak. The wreckage was found six km southeast of Rio Bonito in a dense wooded area. The aircraft was totally destroyed and all 19 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue under VFR mode in IMC conditions. The following contributing factors were identified:
- Overconfidence on part of the captain who was familiar with the area,
- The organizational culture of the company proved to be complacent by not inhibiting the adoption of procedures incompatible with flight safety, such as the low altitude flights made by the instructor captain,
- There was inadequate assessment of the situation by the crew, causing them to fly at a lower altitude than the safe limits under visual conditions unsuitable for visual flight, resulting in the collision of the aircraft with high ground,
- The use of human resources for the operation of the aircraft was unsuitable because of failure to comply with operational standards, leading the crew to perform a passenger flight to the lower altitude limits of safety, under inadequate visual conditions,
- The preparation for the flight proved inadequate because the crew did not have a meteorological analysis of the appropriate level of flight performed, considering that the conditions for the region were overshadowing the Serra do Mar and surrounding areas of low clouds and / or mist, especially on the slopes of the mountain,
- The weather conditions prevailing in the region made visual flight impossible, resulting in the concealment of the elevation at which the aircraft crashed,
- The pilots intentionally not complying with rules of air traffic and civil aviation rules, without grounds, performing flight at low altitude, under conditions of visibility below the limits established for VFR flight, colliding with high grounD,
- The company has not taken appropriate supervisory measures, enabling the existence of a culture of undeveloped flight safety, which prevented advance identification of actions taken by the crew and injured misconception exists in the CRM business, which represented a potential risk to their operations, as well as by the failure of some educational measures provided for in its PPAA (Plan for the Prevention of Aeronautical Accidents).
Final Report:

Crash of a Cessna 525 CJ1 in Alto da Boa Vista: 2 killed

Date & Time: Sep 16, 2005 at 1405 LT
Type of aircraft:
Operator:
Registration:
PT-WLX
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Rio de Janeiro - Jacarepaguá
MSN:
525-0176
YOM:
1997
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total hours on type:
917.00
Copilot / Total hours on type:
2231
Aircraft flight hours:
2231
Circumstances:
The twin engine airplane departed Rio de Janeiro-Santos Dumont at 1402LT on a positioning flight to Jacarepaguá Airport located 23 km southwest from Santos Dumont Airport. After takeoff, the copilot informed ATC he maintained the altitude of 1,500 feet via route Bravo until the coast. Shortly later, while cruising in clouds at an altitude of 1,380 feet, the aircraft struck the slope of Mt Morro da Taquara located in the Tijuca National Park. The wreckage was found near Alto da Boa Vista and both pilots were killed. At the time of the accident, weather conditions were considered as marginal with low ceiling above the mountainous area.
Probable cause:
The accident was the consequence of a controlled flight into terrain after the crew decided to conduct this short flight under VFR mode in IMC conditions. The following contributing factors were identified:
- The visibility was reduced by the presence of a low ceiling over the mountains,
- Poor judgment on part of the crew regarding the existing flight conditions,
- Inadequate assessment of the distance between the aircraft and the ground,
- Continuation of the flight at an unsafe altitude for the area,
- Complacency and indiscipline of the crew,
- Poor flight planning,
- Lack of operational supervision.
Final Report:

Crash of a Lockheed C-130E Hercules near Campo dos Afonsos AFB: 9 killed

Date & Time: Sep 27, 2001 at 1215 LT
Type of aircraft:
Operator:
Registration:
2455
Flight Type:
Survivors:
No
Site:
MSN:
4202
YOM:
1967
Country:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
While descending to Campo dos Afonsos AFB, the crew encountered poor weather conditions with limited visibility due to fog and rain falls. Too low, the four engine aircraft struck the slope of a mountain located about 15 km southeast of the airbase. All nine occupants were killed.