Date:	Wednesday 8 July 2020
Time:	21:09 UTC
Type:	Beechcraft 58 Baron
Owner/operator:	Private
Registration:	PR-OFI
MSN:	TH-607
Year of manufacture:	1975
Fatalities:	Fatalities: 1 / Occupants: 1
Other fatalities:	0
Aircraft damage:	Destroyed
Category:	Accident
Location:	São Paulo-Campo de Marte Airport, SP (RTE/SBMT) -   Brazil
Phase:	Landing
Nature:	Private
Departure airport:	Ubatuba Airport, SP (UBT/SDUB)
Destination airport:	São Paulo-Campo de Marte Airport, SP (SBMT)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
The aircraft took off from Ubatuba Airport, SP (SDUB), bound for São Paulo-Campo de Marte Airport, SP (SBMT), in order to carry out a private flight, with one pilot on board. Near the "Itaquera" position of São Paulo's special VFR air routes, the pilot reported having an engine failure and requested a single-engine approach to Campo de Marte, but never declared a distress or urgency situation. During the landing, after touching down, the pilot decided to go around. The aircraft collided with trees after threshold 12, and crashed into the ground on Braz Leme Avenue, just outside the airport. The aircraft was destroyed, and the pilot suffered fatal injuries.

Inspection of the wreckage confirmed engine #2 was feathered and not operating at the time of impact. Further inspection into the engine revealed two crankcase through-bolts on cylinder #5 had fractured due to material fatigue, overloading the remaining bolts, causing them to detach in flight and resulting in an engine shutdown. These bolts were to be replaced in the last engine overhaul 33 months earlier, but the investigation could not determine whether that was actually done.

Investigation evaluated that the go-around was probably motivated by a higher than usual speed during approach and deep landing, even though it was determined the aircraft could have stopped within the runway limits regardless. It was also determined that the pilot's decision to proceed with landing on SBMT instead of alternating to a nearby airport with fewer restrictions (such as SBGR) demonstrated a lack of thorough assessment of his situation. A night time landing might have affected his situational awareness, contributing to an unstable final approach and decision to go around with very little margin.

Contributing factors:
- Command application — contributed: the aircraft underwent an unstabilized approach, above the recommended speed;
- Piloting judgement — contributed: the PIC opted to go around, despite very little margin for such;
- Aircraft maintenance — undetermined: despite an engine overhaul and mandatory inspections having been conducted, it is possible the procedures employed may not have been sufficiently effective at identifying existing damage to the bolts;
- Motivation — undetermined: this was a return flight during the pilot's wedding anniversary, which may have reduced his situational awareness, thus possibly impairing his ability to notice signs of an impending engine failure, or his decision to not divert;
- Decision-making process — contributed: the decision to continue with the landing in SBMT under the given conditions, as well as the decision to perform a single-engine go-around after touchdown, were demonstrably flawed, with the risks associated with an emergency landing and diversion to a larger runway being much lower.

1. https://g1.globo.com/sp/sao-paulo/noticia/2020/07/08/aviao-de-pequeno-porte-cai-na-regiao-do-aeroporto-campo-de-marte-na-zona-norte-de-sp.ghtml
2. https://www1.folha.uol.com.br/cotidiano/2020/07/aviao-cai-na-regiao-do-aeroporto-campo-de-marte-em-sp.shtml
3. https://sputniknews.com/latam/202007081079833381-at-least-one-dead-after-small-plane-crashes-in-sao-paulo-brazil/
4. https://cdn.jetphotos.com/full/6/19212_1565396365.jpg (Photo)
5. CENIPA report A-082/CENIPA/2020

CAI AVIÃO ✈️ EM SP: A Infraero lamenta o acidente ocorrido com a aeronave BE-58, prefixo PR-OFI, que vinha de Ubatuba para o Campo de Marte. A aeronave, ao tentar fazer o pouso, apresentou problemas e acabou caindo na avenida Braz Leme. pic.twitter.com/OOGowBo5sl

— Maicon Mendes (@Oficialmmendes) July 8, 2020

Compartilhamos um grave acidente aéreo ocorrido nas proximidades do Campo de Marte, no final da tarde; onde 8 viaturas prestam o atendimento com aproximadamente 24 homens do 2º Grupamento de Bombeiros. Ocorrência permanece em atendimento. pic.twitter.com/w8tZ418UQq

— Corpo de Bombeiros PMESP (@BombeirosPMESP) July 8, 2020

... #CorpodeBombeirosdaPMESP #MãosQueSalvam #Cadasegundoconta #ConteComAGente #SaimosEm30s #BombeiroSP #Bombeiros #ForcaParaSalvarVidas pic.twitter.com/KksVLOkx6V

— Corpo de Bombeiros PMESP (@BombeirosPMESP) July 8, 2020

Date/time	Contributor	Updates
09-Jul-2020 05:28	gerard57	Added
09-Jul-2020 05:30	gerard57	Updated [Aircraft type, ]
09-Jul-2020 05:45	harro	Updated [Aircraft type, Cn, ]
09-Jul-2020 07:30	Anon.	Updated [Total occupants, ]
09-Jul-2020 08:21	gerard57	Updated [Time, Source, Narrative, ]
09-Jul-2020 09:27	RobertMB	Updated [Location, Departure airport, Destination airport, Source, Narrative, ]
10-Jul-2020 06:38	cleberjc	Updated [Time, Location, Source, Embed code, ]
11-Jul-2020 10:08	Captain Adam	Updated [Narrative, ]
12-Jun-2021 13:48	Lucas.L	Updated
23-Jun-2021 17:29	Lucas.L	Updated [Location, Source, Embed code, Narrative, ]
24-Jun-2021 20:09	Lucas.L	Updated [Embed code, Category, ]
18-Jan-2025 07:48	lokarutlot	Updated [Time, Location, Source, Embed code, Narrative, Category, ]
18-Jan-2025 07:50	ASN	Updated [Accident report, ]