Incident Overview

Description
A Beechcraft 200 Super King Air, PR-ART, was destroyed when it impacted a hillside near Senador Canedo City, GO, Brazil, while approaching Goinia-Santa Genoveva Airport, GO (GYN). The pilot and five passengers were fatally injured. The flight originated at Bras¡lia-Presidente Juscelino Kubitschek International Airport, DF (BSB). During a VOR approach to runway 32 in heavy rain, the airplane impacted Santo Antnio Hill, 11 km short of the runway. Contributing Factors (translated from Portuguese) – Obesity – undetermined Factors such as obesity and sedentary lifestyle, associated with the high workload in the moments before the collision with the hill, may have contributed to the fact that the task requirement in the final approach exceeded safety margins, leading to a wrong decision of the pilot. – Attitude – unspecified In facing adverse weather conditions and knowing that previous landing aircraft had better visibility at altitude below 3,500 feet in the final approach of the VOR procedure, the pilot may have raised the level of confidence in the situation to the point of continuing descent without considering the risk involved. – Emotional state – undetermined The conditions that were present in the final phase of the flight may have raised the level of tension in the cabin to the point of compromising the management of the situation by the pilot, who left the task of communicating to the passenger. – Decision-making process When considering that the pilot decided to descend from the minimum altitude to achieve visual conditions, it can be assumed that his decision, probably influenced by the experiences of previous aircraft, was made without adequately assessing the risks involved and without considering the option of flying IFR, taking in view of local weather. In addition, the pilot’s decision-making process may have been compromised by the lack of information about the Morro de Santo Antnio in the approach letter – publication of aid for the pilot in flight. – Adverse weather conditions – contributed The images provided by the primary radar of the An polis Control (APP-AN) indicated the existence of strong cloudiness associated with heavy formations in the final approach of the VOR procedure. These conditions influenced the occurrence, causing the collision of the aircraft against the Morro de Santo Antnio, independently of the hypotheses raised in the investigation. – Navigation deviation – contributed The final approach on course 320 ø (instead of the expected 325 ø) led the aircraft to line up with the hill where the collision occurred. – ATS Publication – undefined Morro de Santo Antnio, an obstacle to control the final approach in which the aircraft collision occurred, was not identified in the VOR approach letter for lane 32, as anticipated by CIRTRAF 100-30, a fact that may have contributed to a possible reduction of situational awareness.
Primary Cause
Pilot decision-making lapse, potentially influenced by previous aircraft experiences and a lack of risk assessment, combined with insufficient information regarding the Morro de Santo Antnio, leading to a deviation from the planned approach and a collision with the hill.Pilot decision-making lapse, potentially influenced by previous aircraft experiences and a lack of risk assessment, combined with insufficient information regarding the Morro de Santo Antnio, leading to a deviation from the planned approach and a collision with the hill.Share on: