What happened
On November 14, 2017, at approximately 19:50 UTC, a Piper PA-25-235 aircraft, registered as PR-AAV, crashed near Itápolis, São Paulo, during an agricultural flight training mission. The aircraft was being operated by a flight school for the purpose of instructing a student pilot in low-altitude pesticide application techniques.
The flight instructor, who was monitoring the session from the ground via radio, observed the aircraft lose altitude during a maneuver and disappear from visual contact. Shortly thereafter, a column of smoke was seen. Upon arriving at the scene, the instructor found the aircraft engulfed in flames. The impact and subsequent fire resulted in the destruction of the aircraft and one fatality (the pilot).
The investigation
CENIPA's investigation focused on the flight training progression and the adherence to established safety protocols. The investigation examined the aircraft's maintenance records, the pilot's credentials, and the flight instruction logs. While the engine was found to be in normal operating condition and the weather was favorable, investigators discovered significant irregularities in the training documentation.
A forensic handwriting analysis conducted by the Federal Police revealed that the student pilot's signatures on the flight training logs were inauthentic. Furthermore, the investigation found that the time intervals between successive flight missions were insufficient, leaving no time for the required briefing and debriefing sessions between maneuvers.
Findings
- The student pilot lacked experience in both the specific aircraft model and the low-altitude agricultural flight maneuvers being performed.
- The flight training sequence prescribed in the manual (MCA 58-17) was not followed, as the student began low-altitude training earlier than the authorized phase.
- The lack of adequate time for briefing and debriefing prevented the student from assimilating errors from previous maneuvers and preparing for the next flight.
- The investigation was ultimately interrupted due to the discovery of fraudulent documentation provided by the operator.