What happened
On March 26, 2014, an EMB-201A agricultural aircraft, registration PT-GYC, was performing crop spraying operations near Dom Pedrito, Rio Grande do Sul. After completing the application of agricultural products at a field approximately 7 NM from the departure point, the pilot was returning to the temporary landing strip from which the flight had originated.
During this return leg, the aircraft collided with a grove of eucalyptus trees located between the field and the landing strip. The impact caused the aircraft to strike the ground and subsequently catch fire. The aircraft was destroyed, and the pilot sustained fatal injuries at the scene.
The investigation
CENIPA's investigation examined the aircraft's maintenance records, the pilot's experience, and the organizational structure of the operator, Aerovac Aviação Agrícola Ltda. Mechanical examinations of the aircraft components ruled out structural or engine failure as a cause. Meteorological data indicated favorable conditions for visual flight, though the sun was positioned directly in the pilot's forward field of view during the return leg.
The investigation also looked into the pilot's flight history and the company's operational oversight. It was noted that the pilot had recently completed agricultural pilot training and that the company's management was aware of previous instances of flight indiscipline, such as unauthorized night landings and flying with unauthorized passengers. The investigation also found that the company lacked formal flight safety processes or standardized operational procedures for its pilots.
Findings
- Flight Indiscipline: The pilot was flying below the minimum VFR altitude of 500ft AGL during the return to the strip.
- Organizational Processes: The operator lacked formal supervision, safety management systems, and standardized instructions, granting pilots total autonomy over their flight paths.
- Decision Making: The pilot's decision to fly at such a low altitude was made without an adequate assessment of the risks involved.
- Management Oversight: The company's management failed to implement measures to inhibit known instances of flight indiscipline.
- Potential Maneuver Error: There is a possibility the pilot attempted an aggressive "tree jumping" maneuver (a low-level contour flight) and misjudged the distance to the trees.
- Environmental Factors: The position of the sun may have caused glare, potentially leading to pilot disorientation or a failure to identify the obstacle in time.