What happened
On March 8, 2019, a Piper PA-25-235 agricultural aircraft, registration PR-AAT, was performing fungicide application over a banana plantation in Luís Alves, Santa Catarina. The flight was part of an agricultural operation managed by Banalves Aviação Agrícola Ltda. During the fourth flight of the day, the aircraft experienced a sudden loss of engine power. The pilot performed an emergency landing in a nearby plantation. While the aircraft sustained substantial damage, the pilot emerged from the incident uninjured.
The investigation
CENIPA's investigation established that the engine failure was caused by fuel exhaustion. Although the aircraft was fully compliant with maintenance schedules, including recent 50-hour and 1,000-hour inspections, and the pilot held all necessary certifications and experience, the fuel supply had run dry.
Investigators found that the company utilized an informal refueling process. The pilot was responsible for notifying ground personnel when refueling was required. On this occasion, the pilot became preoccupied with the complex tasks of managing the aircraft and the chemical loading process, leading to a failure to request fuel. The investigation noted that the lack of a standardized, formal refueling procedure left the operation vulnerable to human error, as there were no secondary checks or supervisory barriers to ensure the tanks were replenished.
Findings
- Fuel exhaustion was the direct cause of the engine power loss.
- The pilot experienced a lapse in memory and attention due to the high workload of simultaneous operational tasks.
- The absence of standardized organizational processes for refueling contributed to the error.
- A lack of managerial supervision and formal procedures meant there were no safeguards to prevent the oversight.