What happened
On December 28, 2009, at approximately 17:30 UTC, a Cessna A188B, registration PR-SUB, was performing an agricultural application flight near Aceguá, Rio Grande do Sul. The aircraft departed from an improvised landing strip at Estância Cinco Saltos to apply urea. During the takeoff roll, the aircraft exceeded the available runway length and lifted off without achieving the necessary aerodynamic lift.
Following the loss of lift, the aircraft lost altitude and struck a nearby pond with its left landing gear and left wing. The impact caused the aircraft to rotate onto its back. The aircraft sustained substantial damage, and the pilot sustained fatal injuries after becoming trapped in the overturned cockpit, which was submerged in water and mud.
The investigation
CENIPA's investigation ruled out mechanical failure, as maintenance records and wreckage analysis confirmed the aircraft was airworthy and properly maintained. The investigation also found no medical issues that would have incapacitated the pilot.
Investigators examined the operational procedures, noting that the flaps were in the extended position. This is a common practice among agricultural pilots attempting to force lift-off when rotation speed cannot be reached within the runway limits. The investigation also looked into the pilot's psychological state and professional environment, noting that the pilot was experienced but had been under significant personal and professional pressure to expand business ventures.
Findings
- The aircraft exceeded the runway limits during takeoff without sufficient airspeed.
- The pilot's decision-making process and judgment were contributing factors, influenced by self-imposed pressure to complete tasks quickly.
- The use of flaps to induce lift in short-field conditions increased the risk of an uncontrolled departure.
- A culture of accepting unsafe operational conditions, common in some agricultural aviation sectors, contributed to the accident.