What happened
On January 3, 2011, a Piper PA-25-260, registration PT-DJS, was performing agricultural spraying operations over a banana plantation in Corupá, Santa Catarina. While executing a reversal maneuver, commonly known as a "balão," the pilot lost control of the aircraft, which subsequently struck the ground with high vertical deceleration. The impact was violent, and the aircraft was completely destroyed. The pilot sustained fatal injuries at the scene.
The investigation
CENIPA's investigation focused on the sequence of events and the pilot's operational environment. Investigators found that the aircraft's engine and propeller showed evidence of high power at the moment of impact, and no mechanical failures were identified in the aircraft's systems. The aircraft was within weight and balance limits, and its maintenance records, including the annual inspection, were up to date.
While the pilot was highly experienced and held valid commercial and agricultural licenses, the investigation uncovered significant psychological and organizational stressors. The pilot was reportedly dealing with intense family conflicts and personal financial pressures. Furthermore, the investigation examined the operator's management style, noting a lack of direct operational supervision and formal performance evaluations for pilots working in remote areas.
Findings
- Inappropriate control inputs: The pilot applied improper flight controls during the reversal maneuver, which likely induced an aerodynamic stall at a low altitude, leaving insufficient time for recovery.
- Inadequate organizational supervision: The operator failed to provide adequate oversight of its pilots' operational performance and did not monitor the psychological well-being of crew members.
- Psychological stressors: The pilot was experiencing significant personal and family issues that may have impaired cognitive functions, such as attention, perception, and decision-making.
- Lack of operational support: The company's management structure placed excessive decision-making responsibility on the pilots without providing the necessary follow-up or established safety parameters for aborting missions.