What happened
On April 2, 2008, an EMB 201 aircraft, registration PT-GOT, was performing agricultural spraying operations over a soybean field approximately 12 kilometers northeast of Bagé, Rio Grande do Sul. During a low-altitude pass, the aircraft struck high-voltage power lines, causing an electrical discharge and immediate loss of control. The aircraft subsequently struck the ground in an uncontrolled descent, resulting in the fatal death of the pilot. The impact destroyed the aircraft, which was considered beyond economical repair.
The investigation
CENIPA's investigation established that the pilot was performing spraying maneuvers at an altitude between 1 and 4 meters. The investigation found that the aircraft was operating with several expired documents, including an expired Airworthiness Certificate and an expired Annual Maintenance Inspection. Furthermore, the pilot's professional licenses and medical certificate were also out of date.
Investigators noted that the aircraft was fueled with ethanol, a fuel not approved for this specific model, though no mechanical failure was identified as the cause of the crash. The investigation also examined the cockpit environment, noting that the windshield often became obscured by insects and chemical residue during operations, which could impair visibility. The pilot was also operating without any ground support crew, performing all tasks including refueling and chemical preparation independently.
Findings
- Lack of perception: The pilot failed to identify the high-voltage cables in the flight path.
- Safety culture: The operation was conducted in an irregular manner, prioritizing task completion over established safety procedures.
- Lack of supervision: The absence of a support team or management oversight meant there was no supervision of the high-risk flight planning or execution.
- Operational pressure: Potential stress from delayed schedules due to previous bad weather and the pressure to perform high-risk maneuvers in a complex environment.
- Inadequate equipment: The pilot was using only a lap belt, which failed upon impact.