Investigation Summary
The accident occurred at the end of an exhausting multi-leg tour across Brazil. During the final approach to Guarulhos, the aircraft was positioned for a landing on Runway 09L. However, the approach was not stabilized, and the crew initiated a go-around. Instead of following the published missed approach procedure, which required a right turn to avoid high terrain, the pilot executed a left turn toward the Serra da Cantareira. The investigation highlighted that the crew was specifically unfamiliar with the Guarulhos (GRU) approach and missed approach charts, failing to maintain adequate situational awareness. Communication issues also played a role, as the crew used improper phraseology with air traffic control. The steep terrain of the Serra da Cantareira, combined with night conditions and low visibility, left the crew with no time to react when they realized they were on a collision course with the mountainside.
Final Conclusions
The Aeronautical Accidents Investigation and Prevention Center (CENIPA) concluded the investigation on May 28, 1996. The primary cause was determined to be Controlled Flight Into Terrain (CFIT). Contributing factors included crew fatigue from an extended work period without adequate rest, a lack of cockpit coordination (CRM) characterized by the pilot's authoritarian demeanor and the copilot's passivity, and the crew's failure to adhere to the correct missed approach path. The investigation also noted that the air taxi operator, Madrid Táxi Aéreo, lacked a dedicated flight safety team and had allowed the aircraft's insurance to lapse, suggesting organizational deficiencies.
Video Analysis
No video analysis linked for this case file yet.
Crew Experience
Captain
Jorge Luiz Germano Martins, aged 30.
First Officer
Alberto Yoshiumi Takeda, aged 24, certified for the type but with limited experience.
Systems & Failure Modes
Cockpit Resource Management (CRM)
The investigation found a significant imbalance in the cockpit, where the experienced but fatigued pilot's authoritarian style prevented the inexperienced copilot from challenging the incorrect turn during the go-around.
Missed Approach Procedure
The published procedure for Runway 09L required a specific turn to avoid the 3,900-foot peaks of the Serra da Cantareira; the crew's deviation from this path led directly to the terrain collision.
Interesting Facts
- 01All five members of the band Mamonas Assassinas were killed in the crash.
- 02The pilot had a previous incident in 1991 where he forgot to lower the landing gear on a King Air.
- 03The aircraft's insurance had lapsed eight months prior to the accident due to non-payment.
- 04The crash site was so remote that rescue teams only reached the wreckage the following morning.
- 05Approximately 100,000 people attended the funeral procession for the band members in Guarulhos.
Safety Actions & Advisories
CENIPA Recommendations
The report emphasized the need for air taxi operators to implement formal flight safety programs and strictly adhere to crew duty time limitations to prevent fatigue-related errors.