An 8-year-old girl and 56-year-old man, hit by an aircraft making an emergency landing on a beach at the Costa de Caparica in August 2017, died as a result of pilot error.
Flaws in emergency management and a clear breach of procedures by the flying instructor led to the Cessna 152 being landed on the beach by the trainee pilot, leading to the deaths of Sofia António and José Lima .
On 2 August, a lightweight, two-seater Cessna 152 took off from Cascais Aerodrome, bound for Évora on a training flight.
After reporting an engine failure five minutes after takeoff, the pilot brought the Cesna down on the crowded São João beach, striking the two victims. The beach is at the Costa Caparica to the south-west of Lisbon, just south of the Tejo estuary.
"After the engine failure, it became clear that the instructor did not properly manage the emergency, where he should have followed the basic emergency procedures, not just looking for a solution to the problem of engine failure," reads the final report from the Air Accident Investigators.
Despite the instructor’s 5,000 flight hours, including 3,930 hours in a Cesna 152, it was clear to the investigators that the pilot’s lack of preparation and his failure to follow the correct procedures, led to the accident.
The engine failed due to a blocked carburettor so the accident investigation team recreated the flight in a similar aircraft and in similar atmospheric conditions.
"On the third flight, the pilot took the option of flying straight across the river, and proved this was viable with the tailwind pushing the aircraft smoothly to the junction of the Tejo River where they are at least three options for an emergency landing," reports the GPIAAF team.
The normal procedure would have been to ditch the plane in the water, rather than landing on a busy beach, but the instructor was telling his student, Rui Relvas, what to do, so the 27-year-old "had a passive and reactive role only," flying the aircraft as instructed.
"Numerous attempts were made to restart the engine until shortly before the aircraft hit the sand on the beach. According to the student, during all these attempts, the instructor did not use the checklist as defined in the operations manual," the report adds.
Despite engine problems, the Cessna 152 flew at between 120 and 150 meters in altitude, pushed on by a strong tailwind that helped it cross the Tejo River and only then did the pilot instructor decide to look for a place to land, "leaving little time for risk analysis, and drastically reduced their options in choosing a landing site."
The inspectors, who are there to report, not to accuse, state that "the instructor’s actions were not performed according to the emergency procedures and the checklist. The instructor’s actions and statements he made after the event indicated an inadequate knowledge and understanding of what to do in this sort of emergency.”
The flying instructor, Carlos Conde de Almeida, said a few days after the accident, that he had no regrets and that he was following standard operating procedure, "I did what should be done." The accident investigators disagree.
See also:
1. Cessna pilot is 'not sorry that he landed on the beach' despite two deaths ...
2. Cessna emergency landing - instructor and trainee pilot questioned over two deaths ...
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To download the full accident report, in Portuguese and English, click HERE
