What happened
On March 22, 2019, at approximately 12:30 UTC, a Neiva EMB-201A, registration PT-GYT, was performing agricultural spraying operations near Matão, São Paulo. The aircraft had departed from a landing strip at Fazenda Fiori to apply pesticides to crops. During the flight, while maneuvering at a low altitude, the aircraft's landing gear and the spray boom collided with the crop canopy. Following the impact, the pilot performed an emergency landing. The aircraft sustained substantial damage, while the pilot sustained minor injuries.
The investigation
CENIPA investigators examined the flight profile, the terrain, and the operator's safety management systems. The investigation confirmed that the pilot held valid commercial and agricultural licenses, and the aircraft was airworthy, properly weighed, and balanced, with all maintenance logs up to date. Meteorological conditions were favorable for the operation.
The investigation focused on the terrain characteristics, noting a 5% gradient (a 46-meter elevation change over 950 meters) along the application axis. The flight path at the time of the accident was moving from the lower end of the slope toward the higher end. Additionally, investigators reviewed the operator's Safety Management System (SMS). It was found that while the company utilized operational risk management tools for landing areas, these tools did not formally extend to the application areas themselves, leaving hazard identification for spraying zones to informal processes.
Findings
- Inadequate flight control application and pilot judgment regarding the terrain's upward slope.
- Lack of formal risk management for application areas within the operator's safety manual.
- The pilot's limited experience in this specific type of agricultural flight operation.
- Inadequate managerial supervision regarding the planning and execution of operations in application zones.