What happened
On July 4, 2020, a Laviasa PA-25-260 agricultural aircraft, registration PR-SOH, crashed while performing pesticide application in a banana plantation near Cajati, São Paulo. The flight departed from an unregistered strip known as Fazenda Pedrinhas. During the application process, the pilot failed to notice a steep upward slope in the terrain ahead. In an attempt to avoid the ground, the pilot applied maximum power, jettisoned the load, and attempted a right-hand turn. This maneuver caused the aircraft to lose lift and enter a stall, resulting in a low-speed impact with the ground in a nose-down attitude. The aircraft sustained substantial damage, but the pilot escaped without injury.
The investigation
CENIPA's investigation established that the pilot was properly licensed and medically certified, with sufficient experience in the aircraft type. The aircraft's maintenance records, including engine, propeller, and airframe logs, were up to date, and the weight and balance were within limits. However, the investigation revealed that PR-SOH was not listed in the operator's official operational specification. Furthermore, while the company's safety management manual required a formal operational risk assessment (GRSO) for use of agricultural landing areas, the operator failed to provide the required risk management documentation for the Fazenda Pedrinhas site.
Findings
- The terrain in the application area was highly rugged, with elevation changes of up to 300 meters between peaks and valleys.
- The pilot's inadequate use of flight controls and deficient piloting judgment led to the stall.
- There was a failure in flight planning, as the flight was conducted at low altitudes without adequate consideration of the terrain elevations.
- Ineffective management supervision failed to properly manage the risks associated with the application area.
- The pilot's application technique contributed to the loss of situational awareness regarding the rising terrain.