What happened
On November 9, 2015, at approximately 19:30 UTC, an Air Tractor AT-502B, registration PR-RSA, was performing a local adaptation flight at the Balsas Aerodrome (SNBS) in Maranhão, Brazil. The aircraft was being operated by Ribeirão S/A.
Shortly after takeoff, the aircraft experienced an abrupt pitch-up maneuver, causing it to lose lift and collide with the runway surface. The impact caused the aircraft to catch fire and slide approximately 60 meters along the runway. The pilot sustained fatal injuries.
The investigation
CENIPA's investigation focused on the circumstances surrounding the pilot's transition to the new aircraft type. The investigation established that while the pilot was an experienced agricultural aviator—primarily in Embraer EMB-202 and EMB-201 models—he had only approximately 57 minutes of flight time in the AT-502B.
Investigators examined the operator's hiring practices and training protocols. It was found that the company lacked formal processes for pilot recruitment and did not provide a structured training program or a qualified instructor to assist the pilot during this transition. Furthermore, the investigation noted that the pilot's agricultural pilot rating (PAGA) had expired, and the aircraft's maintenance logs for the airframe, engine, and propeller were not up to date, although the airworthiness certificate was valid.
Findings
- Lack of technical proficiency: The pilot's lack of specific qualification and experience in the AT-502B led to improper control inputs, resulting in an aggressive pitch-up attitude after takeoff.
- Inadequate training and instruction: The absence of an instructor or a formal training program prevented the pilot from managing the aircraft's transition, specifically regarding the risk of entering a stall condition.
- Organizational culture: The operator's culture allowed for informal, unstandardized procedures, including the use of informal hiring practices based on recommendations rather than verified technical competence.
- Inexperience with aircraft type: Despite significant experience in agricultural aviation, the pilot's lack of familiarity with the specific handling characteristics of the AT-502B was a critical factor.
- Language barriers: The pilot lacked proficiency in English, which was the language used in the aircraft's flight manual.