What happened
On December 29, 2009, an EMB-201A aircraft, registration PT-GVO, was performing a ferry flight from São Pedro do Sul to a landing area at Fazenda Mucambo in São Francisco de Assis, Rio Grande do Sul. During the final approach to the unpaved landing strip, the pilot executed a steep left-hand turn to align with the runway. During this maneuver, the aircraft lost control and struck the ground, initially impacting with the left wing before the nose hit the soil. The impact caused the aircraft to spin 180 degrees and subsequently ignited a fire that completely destroyed the airframe.
The pilot sustained minor injuries and was rescued from the wreckage. However, a ground crew member, who may have been improperly positioned within the cabin, sustained fatal head injuries. The aircraft's destruction also resulted in the loss of all onboard documentation and the destruction of a nearby farm fence.
The investigation
CENIPA's investigation focused on the sequence of events during the approach and the configuration of the aircraft. Investigators examined the aircraft's maintenance history, noting that the last annual inspection had been completed approximately 40 flight hours prior. The investigation also looked into the cargo configuration, as the aircraft's hopper was being used to transport 80 liters of aviation gasoline in canisters, along with a fuel pump and a toolbox.
Investigators analyzed the physical evidence of the injuries sustained by the ground crew member. While the official flight plan did not include a passenger, the nature of the head injuries—specifically trauma consistent with striking internal cabin components like the ventilation vent and a metal bar—suggested the individual may have been inside the cabin during the impact. However, the intense fire following the crash prevented definitive proof of the individual's exact location.
Findings
- The pilot performed an aggressive, high-bank turn at low altitude to align with the runway.
- A pilot error in judgment during the approach maneuver likely caused the aircraft to exceed its maximum lift coefficient, leading to an aerodynamic stall and loss of control.
- The aircraft was carrying unauthorized cargo (fuel canisters and tools) in the hopper, which is not a certified compartment for such items.
- The operator's organizational culture demonstrated a lack of formal processes, permitting the transport of non-standard cargo and potentially allowing unauthorized personnel on board.
- The pilot had not performed a ground reconnaissance of the landing strip prior to the approach.