CENIPA, an agency linked to the Brazilian Air Force, concluded the investigations into the accident that claimed the life of singer Marília Mendonça and four other people, in November 2021, and made public, in its final report, its conclusions, this Monday, 15 of May.
The investigation maintains that on the day of the accident, the plane carrying Marília Mendonça and her team did not present mechanical failure nor had human error as the main factor, despite indicating possible error of decision by the pilots, as one of the contributing factors.
The King Air C90A hit the cable of a CEMIG distribution tower, on an unmarked electrical transmission line that was outside the aerodrome protection zone, “[…] since the 69kv line was outside the limits of the Aerodrome Protection Zone (ZPA) established by the PBZPA, it was not characterized as an obstacle that could have an adverse effect on the safety or regularity of air operations…” (CENIPA).
According to ICA 11-408, an object must be signaled and illuminated if:
- In the case of towers, masts, poles, overhead power lines, suspended cables or others […] at a distance that are located within the lateral limits of the transition surface or within 3.000 meters of the inner edge of the approach surfaces…
- In the case of overhead power lines, suspended cables or other objects of similar configuration, which cross rivers.
- When dealing with objects that rise to a height of 150 meters or more.
However, considering that the 69kv line was outside the limits of the SNCT Aerodrome Protection Zone and that it had a height of less than 150 meters and outside the approach or take-off surface, it did not represent an adverse effect on the safety or regularity of operations flights, despite crossing the Ribeirão do Laje, according to the instruction issued and standardized by the Department of Air Space Control, DECEA.
Considering that the Caratinga airfield operates only under visual flight rules (VFR), CENIPA's final report also indicates the piloting judgment as a contributing factor to the crash of the aircraft, "... with regard to the approach profile for landing, there was an inadequate assessment of the aircraft's operating parameters, since the downwind leg was stretched over a distance significantly greater than that expected for an aircraft of “performance category B” in landing procedures under VFR” (CENIPA) .
Standard traffic circuit, applicable for flight and airfield operating visual. The wind leg is the trajectory parallel to the runway, however, in the opposite direction to the landing direction.
In other words, CENIPA states that the pilot could not have lengthened the downwind leg so much and entered a base farther from the aerodrome, even suggesting that the 10-year experience of working in an airline, flying an Airbus A319/320 , may have contributed to the commander's decision to enter a longer final.
Well, being an airline pilot, the author of this article considers the possible attribution of piloting judgment failure as one of the contributing factors to be unfair, since, according to ICA 100-12, item 5.2., “It will be up to the pilot in command of an aircraft flying VFR provides for its own separation from obstacles and other aircraft through the use of vision…” and, item 4.2.1., “The rules described below do not exempt the pilot-in-command from the responsibility of taking the best action to avoid a collision, including maneuvers based on resolution advice provided by ACAS equipment”.
Finally, the collision against the transmission line occurred in a position aligned with the extension of the SNCT runway, 2,5NM from threshold 02 and at a height of 922ft in relation to the runway. At that point, the aircraft would be about 115ft above the ground, but with a ramp equivalent to 3,46° in relation to runway 02.
Although the ROTAER does not indicate the presence of this respective obstacle, in the WAC charts, applicable to visual flights, there is an indication of the high voltage line, but without signaling it as a relevant obstacle.
Another relevant piece of information is that, at the time of the accident, there was no VAC chart (visual approach chart) published, which provides pilots with all relevant information regarding approach, landing and takeoff procedures, although it is not mandatory, according to current regulations. . Today, such a VAC exists, even in view of the recommendations issued by the center to ANAC and DECEA, published on April 20, 2023, specifically indicating the altitude of all relevant obstacles and close to the aerodrome.
For Sérgio Alonso, lawyer for the family of Geraldo Martins de Medeiros, the commander of the C90A, the document attests to CEMIG's responsibility for the accident, despite also pointing to “inadequate assessment” by the commander of the twin-engine aircraft.
“The pilot got into a trap because there was no signaling”, says the lawyer specializing in aviation law, who also asks “if it was flagged, he would have 30 seconds to assess the approach. Without signaling, he had 0,3 seconds, which the acuity of the human eye cannot calculate.”
As for the plane model, although some "experts" (read with cynicism) claim that it does not seem to be safe due to the number of accidents that occurred in the past, the line's production lasted more than half a century, with more than 7.000 units. produced over the years and also for being the third largest fleet of executive aircraft (TPP and TPX category) flying regularly in Brazil, according to the Brazilian Aeronautical Registry, the RAB - ANAC.
Finally, the report makes clear the excellence ed in the maintenance of the air taxi fleet, as well as in the selection process of pilots and respective qualifications and experiences, so much so that the commander responsible for the flight, at the time of the accident, had logged more than 16 thousand hours of flight and several models of aircraft piloted in his curriculum, among them, the Airbus A319/320 and some models of “executive jets” from Cessna.
It is evident that this is now one of the new recurring discussions in the aeronautical community, including the possibility of extending the size of the radius that encomes the aerodrome protection zone, in order to assign signaling to more obstacles that may affect flight safety, mainly at airfields located in mountainous regions, like most of those found in the state of Minas Gerais.
Also, highlight the divergence of requirements and instructions signaled by the investigation commission in the regulation published by ANAC and by the instruction published by DECEA, both regulating aspects of approval of public aerodromes.
It is now up to the civil police to investigate and assign responsibilities, as the final CENIPA report does not bring this type of accusatory conclusions.
CENIPA's final report on the accident with the plane carrying the singer Marília Mendonça and her team can be accessed by clicking here.
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