Investigation Summary
The flight was transporting Eduardo Campos during his 2014 presidential campaign. Upon arriving at Santos Air Force Base, the crew encountered weather conditions near the safety minimums for the NDB approach to Runway 35. Instead of following the full ECHO 1 instrument procedure, the captain attempted a shortcut using the Flight Management System (FMS) to join the final approach, a technique he had used previously in visual conditions. This resulted in a non-stabilized approach with a tailwind component on a wet runway. The crew decided to go around but failed to follow the published missed approach procedure, which required a specific climb and turn sequence. Instead, they performed a low-altitude left turn into clouds. During this maneuver, the aircraft reached bank angles of up to 60 degrees and G-loads exceeding 2.0G. The combination of high workload, poor visibility, and physical forces likely induced somatogravic illusions and spatial disorientation. The aircraft entered a steep, high-speed dive from which the crew did not recover, impacting a residential area at a high pitch-down angle.
Final Conclusions
The Aeronautical Accidents Investigation and Prevention Center (CENIPA) concluded the investigation in January 2016 (Report A-134/CENIPA/2014). The primary cause was a loss of control following spatial disorientation. The report highlighted that the cockpit voice recorder (CVR) had been inoperable since January 2013, depriving investigators of direct evidence of crew coordination. It also noted that while the pilots held C560 type ratings, they had not received specific transition training for the XLS+ model's unique avionics and performance characteristics, which increased their cognitive load during the emergency.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Valid C560 qualification until October 2014.
First Officer
Valid C560 qualification until May 2015; showed signs of fatigue in radio transmissions.
Systems & Failure Modes
Cockpit Voice Recorder (CVR)
The CVR was found at the crash site but contained no data from the accident flight, as it had failed in January 2013 and was never repaired.
Flight Management System (FMS)
Investigators believe the crew relied on the FMS to fly a non-standard approach profile rather than following the published NDB ECHO 1 chart.
Pratt & Whitney Canada PW545C Engines
Post-crash examination confirmed both engines were developing high power at the moment of impact, ruling out engine failure.
Interesting Facts
- 01The aircraft's cockpit voice recorder (CVR) had been inoperable for over 18 months prior to the accident.
- 02The captain was known for using FMS-aided visual approaches to save time, even when IFR procedures were required.
- 03Analysis of the co-pilot's voice communications indicated signs of fatigue and somnolence.
- 04The RR NDB was non-functional on the day of the accident, and the crew failed to cross the SAT NDB, which was the only available aid for determining the missed approach point.
- 05The aircraft impacted the ground at a steep dive angle between 22 and 35 degrees.
- 06Eleven people on the ground sustained injuries due to the impact and resulting fire in the residential neighborhood.
Safety Actions & Advisories
Pilot Training Requirements
ANAC published Supplementary Instruction IS 61-004 to clarify that pilots must undergo specific flight instruction and proficiency checks when switching between different models within the Cessna 560XL family.
CVR Maintenance Oversight
The investigation highlighted the need for stricter enforcement of regulations regarding inoperative flight recorders, as the aircraft had flown for over a year with a broken CVR.
Known Controversies & Unanswered Questions
Conflicting Causal Claims
Reference ↗While the official CENIPA report (A-134/CENIPA/2014) focused on pilot spatial disorientation and lack of training, some external reports and social media summaries suggested air traffic control errors or mistakes by 'American pilots' were factors, despite the crew being Brazilian and the official report placing primary responsibility on the crew's non-standard maneuvers.