What happened
On October 3, 2005, an EMB-201A, registration PT-UAH, was performing a simulated agricultural flight mission at the Itápolis Aerodrome in São Paulo. The pilot, a trainee in an agricultural pilot formation course, was executing a series of maneuvers under the observation of a ground instructor communicating via VHF radio.
After completing a pass along runway 01, the pilot intended to perform a left-hand turn to execute a reversal maneuver (a "balão" maneuver used in crop dusting) to approach the opposite runway. However, as the aircraft crossed the threshold of runway 19, the pilot initiated a right-hand turn. This turn caused the aircraft to disappear behind a grove of eucalyptus trees, breaking the instructor's line of sight.
An instructor on the ground attempted to regain visual contact by moving toward the runway. Upon spotting the aircraft again, the instructor observed it in a steep descending attitude with a high bank angle. The aircraft struck an orange grove approximately 500 meters from the runway threshold, resulting in an explosion and fire. The pilot sustained severe burns and passed away seven days after the accident.
The investigation
CENIPA's investigation focused on the flight dynamics and the pilot's decision-making during the maneuver. The investigation established that the aircraft was within weight and balance limits and that the engine was producing power at the time of impact. The investigation also noted that the pilot had recently been approved for a solo flight following a successful training session earlier that day.
Investigators examined the pilot's psychological state, noting high levels of motivation to complete the course due to personal reasons, as well as potential overconfidence following recent instructional success. The investigation also looked into the operational parameters of the turn, specifically whether the bank angle exceeded the performance capabilities of the aircraft at its current weight.
Findings
- The pilot attempted a reversal maneuver without sufficient lateral clearance from the runway axis.
- The aircraft was operating at a high weight, as the pilot had not yet released any simulated load during the maneuver.
- The pilot likely executed an excessive bank angle during the turn, leading to an aerodynamic stall at a low altitude from which recovery was impossible.
- Potential overconfidence and a desire to maintain the maneuver's momentum to avoid "failing" in front of observers may have influenced the pilot's judgment.
- The presence of natural obstacles (the grove) prevented the ground instructor from providing timely radio intervention during the critical phase of the turn.