What happened
On May 10, 2000, a Piper PA-25-260, registration PT-DOG, operated by Aero Agrícola Caiçara Ltda., departed from the Registro aerodrome in São Paulo for an agricultural spraying mission. The aircraft was carrying 80 liters of gasoline and 200 liters of pesticide, destined for a banana plantation approximately 20 km away.
During the flight at low altitude, the engine experienced a failure approximately three minutes after takeoff. The aircraft lost altitude rapidly and struck a hillside at a steep 75-degree angle. The impact was followed by an explosion and a fire that completely consumed the aircraft. The pilot sustained fatal injuries and died at the scene.
The investigation
CENIPA investigators examined the engine, which had been recently replaced with a unit from another aircraft (PT-DOX) during a 100-hour inspection just six days prior to the accident. The investigation revealed several technical irregularities in the engine assembly, including excessive wear on the camshaft lobes, irregular piston pin assembly, and improperly adjusted spark plug electrodes.
Furthermore, the investigation found that the aircraft was operating from an aerodrome that had been officially closed since 1987. The facility lacked necessary infrastructure, and the fuel handling procedures were found to be highly inadequate, with no proper filtration or protection against contamination. The investigation also noted that the engine's startup on the day of the accident was difficult and irregular, yet the pilot proceeded with the flight.
Findings
- Deficient Maintenance: The 100-hour inspection performed shortly before the accident involved improper engine assembly and lacked proper documentation of functional tests.
- Deficient Judgment: The pilot elected to take off despite observing significant engine irregularities and unstable RPM during the startup phase.
- Deficient Planning: The flight was conducted at a low altitude over irregular terrain, which left the pilot with insufficient time to execute an emergency landing after the engine failure.
- Deficient Supervision: The operator failed to supervise maintenance services and lacked adequate controls for fuel quality and storage.
- Operational Non-compliance: The aircraft was being operated from an unauthorized and closed aerodrome.