What happened
On March 1, 2022, at approximately 10:50 UTC, a PA-25-260 aircraft, registration PP-IAI, was performing an agricultural chemical application flight in a rural area of Eldorado, São Paulo. During the third pass of the second sortie of the day, the aircraft collided with vegetation within a banana cultivation area.
The impact caused substantial damage to the aircraft. The forward section, including the cabin and fuselage, was extensively destroyed. The engine detached from the structure and came to rest two meters away from the main wreckage, while the right wing was found separated from the fuselage, embedded in a banana tree. The pilot sustained fatal injuries.
The investigation
CENIPA's investigation revealed several critical discrepancies regarding the aircraft's airworthiness and the operator's management. Although the pilot was qualified and held valid medical and agricultural ratings, the investigation found that the aircraft was operating under an invalid Special Flight Authorization (AEV). While the aircraft had been converted to use ethanol, the engine had been replaced without the necessary notification or registration with ANAC.
Investigators also identified significant irregularities in maintenance and operational records. While inspections were documented, the monthly utilization control sections were out of date, and the Journey Logbook contained inconsistencies. Furthermore, discrepancies between various maintenance work orders and the aircraft's logbooks made it impossible to verify compliance with essential Airworthiness Directives (ADs) regarding wing attachment structures.
Findings
- Organizational culture with low adherence to flight safety principles was a primary contributing factor, evidenced by deficient hour-logging and inadequate communication of safety issues.
- Inadequacies in aircraft maintenance services and inconsistent record-keeping prevented the verification of critical inspections for corrosion and cracking.
- Ineffective managerial oversight was noted, specifically regarding the failure to ensure the use of personal protective equipment, as the pilot was not wearing a helmet at the time of the crash.
- Deficient management planning and a lack of structured organizational procedures contributed to the degradation of operational safety and the aircraft's airworthiness status.