What happened
On February 23, 2017, a Piper PA-25-235, registration PT-WBO, was performing agricultural spraying operations over banana plantations in Garuva, Santa Catarina. The aircraft took off from a local landing area to apply fungicide. Approximately 30 minutes into the mission, while maneuvering around a hill between application passes, the aircraft collided with the ground in a near-vertical, pitch-down attitude. The impact caused substantial damage to the engine, propeller, wings, and fuselage. The pilot sustained fatal injuries.
The investigation
CENIPA investigators examined the wreckage and the pilot's medical history. Technical analysis of the engine and propeller ruled out mechanical or structural failure, confirming the engine was running normally at the time of impact. While investigators found an unapproved modification to the elevator lever intended to assist the pilot due to a previous arm injury, there was no evidence this contributed to the crash.
Medical evidence revealed the pilot was managing diabetes and hypertension. A medication organizer found at the scene contained several drugs, including XigDuo XR and Nebilet. Investigators also noted the pilot's habit of consuming large quantities of sugary and carbonated drinks. Furthermore, the pilot was known for a bold and aggressive flying style, often executing high-load maneuvers during course reversals.
Findings
- Inappropriate diet: The excessive consumption of high-glycemic foods and drinks likely caused fluctuations in blood glucose levels, potentially leading to hypoglycemia or hyperglycemia.
- Medicine intake: The simultaneous use of XigDuo XR and Nebilet is not recommended for pilots, as this combination can mask the physiological symptoms of hypoglycemia, preventing the pilot from recognizing a medical emergency.
- Piloting judgment: The pilot's aggressive maneuvering style may have led to a misjudgment during a complex turn, resulting in the loss of control in flight.
Safety action
CENIPA issued recommendations to the Brazilian National Civil Aviation Agency (ANAC) to disseminate lessons regarding the risks of incompatible drug interactions and unapproved aircraft modifications. Additionally, the agency was urged to work with accredited medical clinics to better educate crews on the dangers of specific medication combinations.