What happened
On January 11, 2020, at approximately 11:30 UTC, a collision occurred at an agricultural landing strip in Paraíso do Norte, Paraná, involving two aircraft operating for the same company. The first aircraft, a Cessna A188B registered as PT-WHY, was initiating its takeoff roll for a sugarcane fertilization mission. Simultaneously, an Embraer 201A, registered as PT-UBH, was taxiing to an escape area after having just completed a landing.
During the takeoff roll, the right wing of the PT-WHY struck the left wing and fuselage of the PT-UBH. The impact was severe enough to tear the wing from the PT-WHY, and debris struck the cockpit of the PT-UBH. Both aircraft sustained substantial damage, but both pilots escaped the incident without injury.
The investigation
CENIPA's investigation focused on the operational environment and the visibility constraints at the landing site. The investigation established that the pilots were fully qualified, with valid medical certificates and appropriate agricultural flight ratings. Both aircraft were airworthy and within weight and balance limits.
The investigators examined the landing strip's physical characteristics, noting a significant 30-meter elevation difference between the two ends of the strip. They also reviewed the company's safety management processes, specifically looking at how risks were identified for simultaneous operations in the same area.
Findings
- The steep gradient of the runway, combined with the pilot's seating position in the Cessna A188B, significantly restricted forward visibility.
- The pilot of the PT-WHY only became aware of the presence of the PT-UBH once the aircraft gained enough speed to lift its nose.
- There was a lack of adequate risk assessment regarding the simultaneous operation of two aircraft at this specific location, given the runway's irregular terrain and limited visibility.
- The company's management oversight failed to properly identify hazards and mitigate risks related to the use of the narrow escape areas and the physical limitations of the landing strip.
- The pilots' flight planning and judgment contributed to the incident, as the takeoff was initiated before confirming the runway was clear.