What happened
On February 4, 2017, a Cessna A1-88B, registration PR-SEP, operated by SEPAL Serv. Esp. de Pulverizações Aéreas Ltda., was performing an agricultural transit flight from São Sepé Aerodrome to a nearby landing area known as Cabanha Esperança in Rio Grande do Sul. The flight was conducted without a filed flight plan.
During the landing sequence, the aircraft's right-side spray boom made contact with a soybean crop. This contact caused the pilot to lose control of the aircraft, leading to a collision with the ground. The aircraft veered off the right side of the landing strip and came to rest within the plantation. The pilot was uninjured, but the aircraft sustained substantial damage.
The investigation
CENIPA investigators examined the physical dimensions of the landing site and the aircraft. The landing area was approximately 15.7 meters wide at the point of contact. The aircraft has a wingspan of 12.74 meters, and the total length of the spray booms is 7.5 meters. At the time of the accident, the soybean crop was approximately 0.70 meters high, while the spray booms sit roughly 0.60 meters above the ground when the aircraft is landed.
The investigation focused on the adequacy of the landing strip width relative to the aircraft's configuration and the operational oversight provided by the operator. Investigators also reviewed the pilot's decision-making process and the company's management of agricultural landing site selection.
Findings
- Inadequate landing strip width: The pilot attempted to land on a strip that was too narrow for the aircraft's operational configuration, specifically regarding the clearance required for the spray booms.
- Management and supervisory failures: The operator failed to ensure that the selected landing area met safety requirements for agricultural operations, indicating a lack of proper oversight and a failure to adhere to regulatory standards for site assessment.
- Flawed decision-making: The pilot's judgment was compromised by attempting a landing on an extremely narrow and irregular surface.
- Organizational culture: The investigation identified a weak safety culture within the organization, as the operational risks associated with the site selection were not properly mitigated through proper flight planning or risk management.