What happened
On February 23, 2007, an EMB-201A, registration PT-GSD, was performing agricultural spraying operations over a soybean plantation at Fazenda Boi Preto, near Balsas, Maranhão. During the second pass of a spraying stage, the aircraft struck a tree branch from the native Cerrado vegetation at an altitude of approximately ten meters.
The impact caused the aircraft to lose altitude, leading the right wing to strike a second tree. This secondary collision triggered a 1/2 turn (180-degree spin), resulting in a subsequent impact with the ground. The aircraft sustained fatal damage, and the pilot died at the scene.
The investigation
CENIPA's investigation focused on the operational environment and the airworthiness of the aircraft. Investigators found that the aircraft's Certificate of Airworthiness was suspended because the annual maintenance inspection had not been performed. Furthermore, the aircraft's engine, propeller, and airframe logbooks had not been updated since 2005.
Records from the pilot's personal notebook indicated recent mechanical discrepancies, including issues with fuel flow and engine RPM. While the investigation could not definitively confirm a mechanical failure, the lack of maintenance oversight meant that critical components may have exceeded their service life. The investigation also examined the pilot's work conditions, noting a long working day and a compensation structure tied to the area sprayed, which incentivized high-risk operations.
Findings
- Pilot fatigue was a contributing factor, as the pilot was completing a ten-hour workday involving high-intensity, low-altitude maneuvers, noise, and chemical exposure.
- Organizational culture contributed to the accident, as the pilot's remuneration was proportional to the area sprayed, encouraging the acceptance of long hours and unsafe operating conditions.
- Inadequate supervision was identified, as the operator allowed the aircraft to operate with a suspended Certificate of Airworthiness and expired maintenance records.
- Psychological factors, specifically high personal motivation to secure future employment, led the pilot to accept substandard working conditions and an unairworthy aircraft.