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ASN Wikibase Occurrence # 192954
Last updated: 26 May 2018
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Date:19-JAN-2017
Time:13:44 LT
Type:Silhouette image of generic BE9L model; specific model in this crash may look slightly different
Beechcraft C90GT King Air
Owner/operator:Emiliano Empreendimentos e Participações Hoteleiras
Registration: PR-SOM
C/n / msn: LJ-1809
Fatalities:Fatalities: 5 / Occupants: 5
Other fatalities:0
Airplane damage: Written off (damaged beyond repair)
Category:Accident
Location:Mar de Paraty, Rio de Janeiro -   Brazil
Phase: Approach
Nature:Executive
Departure airport:Campo de Marte (MAE/SBMT), Sao Paulo
Destination airport:Paraty Airport (SDTK), Rio de Janeiro
Investigating agency: CENIPA
Narrative:
A Beechcraft C90GT King Air crashed into the waters off Ilha Rasa, 2km from the runway of Paraty Airport. Five occupants are confirmed to have died.

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.

Sources:

https://noticias.uol.com.br/politica/ultimas-noticias/2017/01/19/o-que-se-sabe-sobre-a-queda-do-aviao-em-que-estava-teori-zavascki.htm
http://g1.globo.com/rj/sul-do-rio-costa-verde/noticia/2017/01/aviao-cai-no-mar-em-paraty-na-costa-verde-do-rio.html
http://www.nasdaq.com/article/plane-carrying-brazil-supreme-court-judge-crashed-into-sea--source-20170119-01164
http://www.jetphotos.net/photo/8227524

Accident investigation:
cover
  
Investigating agency: CENIPA
Status: Investigation completed
Duration: 1 year
Download report: Final report


Revision history:

Date/timeContributorUpdates
19-Jan-2017 18:48 Diogo Saavedra Added
19-Jan-2017 18:50 harro Updated [Aircraft type, Cn, Operator, Damage, Narrative]
19-Jan-2017 20:02 Geno Updated [Departure airport, Destination airport, Source]
19-Jan-2017 20:09 Anon. Updated [Total fatalities]
19-Jan-2017 20:11 harro Updated [Total fatalities, Phase, Nature, Destination airport, Narrative]
19-Jan-2017 20:12 harro Updated [Time, Narrative]
20-Jan-2017 07:12 zeehkaev Updated [Total fatalities, Total occupants, Nature, Source, Narrative]
20-Jan-2017 11:20 Aerossurance Updated [Aircraft type]
20-Jan-2017 12:25 TB Updated [Operator, Other fatalities, Narrative]
20-Jan-2017 13:29 Anon. Updated [Narrative]
21-Jan-2017 07:54 cleberjc Updated [Time, Departure airport, Destination airport]
24-Jan-2018 14:59 harro Updated [Time, Operator, Narrative]

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