What happened
On December 13, 2012, an EMB-201A aircraft, registration PT-GXN, was performing its sixth takeoff of the day for an agricultural spraying mission in Santana Velha, Uruguaiana, RS. The aircraft was operating from an unpaved, gravel runway measuring 550 meters in length. During the takeoff roll from runway 09, the aircraft failed to lift off despite reaching the end of the available runway. The aircraft overran the threshold, collided with an elevation located two meters beyond the runway end, and subsequently overturned. The impact caused substantial damage to the airframe, and the pilot sustained fatal injuries.
The investigation
CENIPA's investigation examined the aircraft's mechanical condition, the pilot's medical history, and the operational environment. The investigation confirmed that the aircraft's engine and accessories were functioning normally and that all maintenance logs were up to date. The investigation also noted that the runway length was shorter than the minimum dimensions recommended by the manufacturer for the aircraft's takeoff weight.
Medical analysis revealed that the pilot had a history of cardiovascular issues, including a coronary stent implant from 2010 and hypertension. While the pilot held a valid medical certificate, investigators explored the possibility of a medical event, such as syncope, occurring during the takeoff roll. A witness noted that the pilot appeared to have made no attempt to apply brakes or take corrective action during the overrun. Furthermore, the investigation looked into the organizational pressures of agricultural aviation, where high workloads during harvest seasons can lead to fatigue and physiological stress.
Findings
- The aircraft overran the runway and collided with an obstacle due to inadequate flight planning and runway selection, as the strip did not meet manufacturer requirements.
- The company's management planning was insufficient, as it allowed operations on a runway that lacked the necessary dimensions for the aircraft's performance.
- There was a lack of managerial oversight, leaving the pilot with total autonomy to manage his own flight operations and environmental risks.
- Potential physiological factors, including fatigue and the possibility of a cardiac-related loss of consciousness, may have prevented the pilot from executing an aborted takeoff procedure.
- The high-pressure environment of the harvest season and the culture of accepting strenuous working conditions in agricultural aviation may have contributed to the pilot's physical exhaustion.