What happened
On December 15, 2008, an EMB-201 aircraft, registration PT-GFL, was performing agricultural spraying operations near Uruguaiana, Rio Grande do Sul. After taking off from a temporary landing area, the engine ceased operation. The pilot attempted to restart the engine by switching fuel tanks and activating the auxiliary electric fuel pump, but was unsuccessful. Consequently, the pilot performed an emergency forced landing into a rice field. The aircraft sustained severe damage to the landing gear, wings, propeller, and engine, though the pilot emerged uninjured.
The investigation
CENIPA's investigation established that the aircraft was within weight and balance limits and that all maintenance inspections were up to date. The investigation focused on the sequence of refueling and fuel management during the spraying mission. It was noted that the pilot was managing multiple responsibilities, including flight execution, supervision, and administrative tasks. The investigation also identified a lack of standardized operational procedures and training programs within the operator's organization, noting that checklists and manuals were not consistently utilized by the crew.
Findings
- The engine failure was caused by fuel starvation resulting from the pilot failing to select the fullest fuel tank before takeoff.
- The pilot had a habit of using the right wing tank for spraying and the left tank for transit, which contributed to the oversight during the final takeoff.
- The pilot failed to perform the required checklist procedures after refueling the right tank.
- High workload and the accumulation of supervisory and administrative duties likely impacted the pilot's performance.
- Inadequate management oversight allowed for non-standardized operational practices, such as the omission of checklists.
Safety action
CENIPA issued several safety recommendations, including:
- To the operator: Implement control mechanisms for operational procedures, ensure crew retraining, and establish specific protocols for aircraft reconfiguration and refueling.
- To agricultural flight schools: Standardize training regarding normal and emergency procedures, emphasizing the importance of checklist usage.
- To SINDAG: Evaluate the necessity of increasing personnel during operations to minimize pilot workload.
- To ANAC: Disseminate the lessons learned from this investigation to agricultural operators to highlight the risks of deviating from operational procedures.