What happened
On December 10, 2011, an EMB-201A aircraft, registration PT-GUV, was performing a takeoff roll at an agricultural landing strip known as "Pista do Solom" in Arroio Grande, Rio Grande do Sul. The aircraft was being operated by Samer Aviação Agrícola Ltda. for the purpose of aerial pesticide application.
After traveling approximately 130 meters along the dirt runway, the pilot lost control of the aircraft, causing it to veer toward the left side of the strip. The left main landing gear struck a drainage ditch located at the edge of the field, which triggered a rollover. The aircraft sustained substantial damage, and the pilot sustained fatal injuries.
The investigation
CENIPA investigators examined the condition of the landing site and the operational context of the flight. Although the operator had declared the runway to be 850 meters long and 14 meters wide, the investigation found the width was actually approximately 10 meters, and the length was likely shorter than reported. The surface was composed of irregular earth and contained a drainage ditch.
The investigation also looked into the pilot's recent history. The pilot was a highly experienced professional with over 3,500 flight hours, but had recently returned to flying after a serious accident in 2004. Investigators noted that the pilot had expressed concerns about the condition of the landing strip on the day of the accident but ultimately decided to proceed with the mission.
Furthermore, the investigation reviewed the company's management structure. It was found that while a Flight Safety Agent was appointed, their presence was sporadic and did not provide effective operational supervision. The investigation also noted that the landing area was frequently used by heavy machinery and trucks, leading to significant terrain degradation.
Findings
- Complacency and attitude: The pilot's decision to operate under marginal safety conditions was influenced by a desire to regain professional acceptance within the agricultural aviation community following his return to flight after a long medical hiatus.
- Inadequate flight planning: There was a lack of adequate risk assessment regarding the specific hazards of the landing strip, as there were no effective methods or structures in place to support flight planning or hazard identification.
- Lack of managerial oversight: The absence of proper management supervision regarding the planning and execution of operations allowed the aircraft to be operated under unsafe conditions.
- Operational environment: The culture of agricultural aviation, which often involves high tolerance for adverse conditions and minimal infrastructure, contributed to the acceptance of substandard landing sites.