What happened
On January 8, 2019, at approximately 17:00 UTC, a Cessna A188B, registration PT-OXK, was performing an agricultural spraying mission over a rice field at Fazenda Sobradinho, located in Arroxi Grande, RS. The aircraft was operated by Aeroagrícola Sureña Ltda. for the purpose of applying urea.
The pilot had been conducting several takeoff and landing cycles throughout the day. During the afternoon takeoff, the aircraft utilized the full length of the available landing strip. Although the aircraft became airborne, it struck the terrain immediately after leaving the runway surface. The impact resulted in substantial damage to the aircraft, while the pilot sustained minor injuries.
The investigation
CENIPA's investigation focused on the performance of the aircraft and the environmental conditions at the time of the accident. While the pilot was fully rated and experienced, the investigation noted that the aircraft's takeoff performance was significantly degraded compared to earlier in the day. Although the pilot attempted to use flaps beyond 10° to mitigate the loss of lift, the collision was unavoidable.
Investigators examined the runway conditions, noting that the surface was not entirely dry or hard, and temperatures had risen significantly since the morning. Furthermore, the investigation identified discrepancies in the aircraft's maintenance records, noting that the engine and propeller logbooks lacked proper ANAC authorization codes and the propeller logbook incorrectly listed a different registration, PT-TEX.
Findings
- The aircraft was within weight and balance limits, but the takeoff roll distance increased due to degraded runway conditions (wet surface and higher temperatures).
- Inadequate pilot judgment regarding the aircraft's reduced performance capabilities in changing environmental conditions.
- Incomplete flight planning and risk management, as the operator's risk assessment failed to account for changes in runway surface characteristics.
- Deficiencies in management supervision regarding maintenance documentation and record-keeping.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to oversee the operator in the following areas:
- Improving administrative mechanisms for documenting maintenance services in aircraft, engine, and propeller logbooks.
- Enhancing flight planning, risk management, and management supervision protocols.
- Providing pilots with specialized training in agricultural flight operations, specifically focusing on safe flight planning and piloting techniques.