What happened
On January 21, 2009, a Cessna A-188B, registration PT-FEN, was performing agricultural spraying operations at Fazenda Rancharia in Monte Carmelo, Minas Gerais. The aircraft was operating at a low altitude during a turnaround maneuver (balloon turn) when the pilot lost control of the aircraft near a high-voltage power line located on the higher part of the terrain.
During the maneuver, the pilot attempted to avoid a collision with the power lines by increasing the bank angle and reducing power to attempt a landing parallel to the wires. The pilot also jettisoned the chemical load to reduce weight. However, the aircraft lost lift and collided with the ground. The impact resulted in the destruction of the aircraft and caused serious injuries to the pilot.
The investigation
CENIPA's investigation established that the pilot was fully qualified with valid commercial and agricultural licenses, and the aircraft was airworthy, with all maintenance records up to date and operating within weight and balance limits. Meteorological conditions were favorable for flight.
The investigation examined the pilot's experience, noting that this was his first agricultural season, and he had previously been involved in three incidents since joining the company. The investigation also scrutinized the company's operational procedures, finding that there was no standardized protocol for managing obstacles like power lines. Instead, an informal arrangement existed where the pilot was permitted to fly above the lines because he expressed discomfort with flying below them.
Analysis of the wreckage showed a concentrated debris field consistent with a low-speed horizontal impact. The propeller damage suggested a low-power condition at the time of impact, supporting the pilot's account of reducing power during the maneuver.
Findings
- Improper flight maneuvers: The pilot's decision to increase the bank angle while at a low airspeed and high pitch attitude led to an aerodynamic stall.
- Decision-making and judgment: The pilot's attempt to manage the risk of the power lines through unstandardized maneuvers contributed to the loss of control.
- Lack of organizational standardization: The company lacked clear, standardized procedures for encountering obstacles, relying instead on informal agreements that bypassed established best practices.
- Pilot experience: The pilot's limited experience in agricultural aviation influenced his risk assessment and maneuvering during the critical phase of the flight.