What happened
On March 30, 2016, at approximately 10:00 UTC, two agricultural aircraft, a PA-25-235 (registration PR-SRM) and a PA-25-260 (registration PR-WKK), were engaged in fungicide spraying operations over banana plantations in Luiz Alves, Santa Catarina.
The PR-SRM departed from the Banalves Aviação Agrícola LTDA base at 09:52 UTC, followed shortly by the PR-WKK at 09:57 UTC, both performing similar spraying tasks in the same area. During the fourth spraying pass of the PR-SRM, the two aircraft collided in mid-air. The impact caused the PR-WKK to crash into the plantation, resulting in the total destruction of the aircraft and the death of the pilot. The pilot of the PR-SRM was able to return to the company base, though the aircraft sustained substantial damage to the engine, propeller, and left wing. The pilot of the PR-SRM survived the accident uninjured.
The investigation
CENIPA's investigation focused on the operational environment and the lack of coordination between the two flights. Investigators examined the aircraft maintenance records, which showed both planes were up to date with their inspections. The investigation also reviewed the meteorological conditions, noting that while some fog was reported nearby, visibility at the site of the accident was favorable for visual flight rules (VFR).
A critical finding was the lack of communication equipment; neither aircraft was equipped with VHF radios, making coordination between the two aircraft impossible once they were airborne. Furthermore, the investigation looked into the organizational culture of the operator, noting a lack of formal flight briefings and inadequate management of operational information.
Findings
- Lack of communication: The absence of VHF radios prevented any coordination or separation between the aircraft during flight.
- Inadequate flight planning: Pilots lacked updated maps and information regarding lateral boundaries, obstacles, or the specific locations of nearby spraying activities.
- Management failures: The company did not provide updated operational maps or formal daily briefings to coordinate flight paths and avoid simultaneous operations in close proximity.
- Organizational culture: A lack of a safety reporting culture and a management style that discouraged dialogue contributed to a high-risk operational environment.
- Operational complexity: The high-pressure nature of agricultural spraying, combined with the lack of situational awareness regarding nearby traffic, contributed to the collision.