What happened
On March 13, 2016, an Embraer EMB-202A, registration PT-AHE, was performing agricultural spraying operations at Fazenda Sementes Dallazen in Palmeira das Missões, Rio Grande do Sul. During takeoff, the pilot heard an unusual noise inside the cabin and continued the climb. Shortly after rotation, the right-side door handle failed, causing the door to partially open while the pilot was executing a right-hand turn.
Distracted by the opening door, the pilot attempted to relock it while maneuvering. Upon refocusing on the flight path, the pilot realized the aircraft was at a low altitude and on a collision course with an irrigation pivot. To avoid the obstacle, the pilot performed an abrupt left-hand turn, resulting in a heavy landing in a soybean field. The aircraft sustained substantial damage, but the pilot escaped uninjured.
The investigation
CENIPA investigators examined the aircraft's door mechanisms and maintenance records. Technical analysis of the broken handle by the Department of Aerospace Science and Technology (DCTA) revealed that the upper right internal latch had failed due to fatigue. This fatigue originated from stress concentrators caused by surface corrosion, which had been facilitated by the peeling of the protective paint.
Investigators also found that the other three door handles on the aircraft exhibited similar signs of paint peeling and corrosion. While the aircraft's maintenance manual required inspections of windows and doors every 50 flight hours, the investigation noted that the specific requirements for inspecting metal parts, such as welds and corrosion, were not clearly being applied by the operator's maintenance personnel. Following the accident, the maintenance manual was updated to provide more explicit instructions regarding the inspection of door hinges, latches, and mechanisms.
Findings
- The primary cause of the door failure was material fatigue associated with corrosion caused by the loss of protective paint on the metal components.
- The pilot's decision to prioritize securing the cabin door over maintaining flight path control during a critical phase of flight contributed to the loss of situational awareness.
- The operator's preventive maintenance program was deficient regarding the inspection of metallic parts and corrosion as required by the maintenance manual.
- The pilot's judgment was impacted by the distraction of the mechanical failure during a low-altitude, low-speed maneuver.