What happened
On November 29, 2015, an EMB-201A agricultural aircraft, registration PT-GTR, crashed while performing herbicide application maneuvers near São Vicente do Sul, Brazil. The aircraft was operating from a landing strip at Fazenda Rodeio. During the second reversal turn of the application cycle, the engine experienced a significant loss of power. This power loss prevented the pilot from successfully completing the maneuver, leading the aircraft to strike the ground. The impact destroyed the aircraft and resulted in the death of the pilot.
The investigation
CENIPA investigators examined the wreckage and found that the engine's power loss was directly linked to an obstruction in the servoinjector's impact air jet (gicleur). This obstruction caused an improper air/fuel mixture, leading to a delayed acceleration and power drop when the pilot attempted to accelerate after the application shot.
The investigation also revealed significant maintenance irregularities. Evidence of improvised and non-aviation grade repairs was found, including the use of thread seal tape (fita veda rosca) on connections and the presence of urea deposits in the engine crankcase. Furthermore, the aircraft's logbooks and maintenance records were not up to date, making it impossible to verify the total flight hours since the last inspection.
Regarding the human factors, investigators noted the presence of an inactive cannabis metabolite in the pilot's system, though they could not confirm if any residual impairment existed at the time of the flight. The investigation also considered the possibility that the setting sun may have caused glare, hindering the pilot's vision during the critical maneuver.
Findings
- Engine failure caused by an obstruction in the servoinjector air jet, leading to a lean fuel mixture and delayed engine response.
- Improper maintenance practices, characterized by the use of non-aviation materials and a lack of standardized maintenance controls.
- Organizational failures, including a lack of formal management structure, absence of a Safety Management System (SMS), and a lack of operational supervision.
- Inadequate record-keeping, specifically regarding the failure to maintain updated aircraft and engine logbooks.
- Environmental and physiological factors, including potential solar glare and the possible influence of fatigue or residual effects of substance use.