What happened
On January 10, 1995, an EMB-201 Ipanema, registration PT-GFV, was performing an agricultural spraying mission at Fazenda Passo Fundo in Primavera do Oeste, Paraná. During the takeoff roll from an unregistered, unpaved airstrip, the aircraft struck a wire fence post with its tail skid. The aircraft continued its path, striking a second fence post with its spray nozzles, before the left wing collided with a 7-meter-tall tree pole. Following these impacts, the aircraft struck the ground and caught fire. The fire consumed approximately 70% of the aircraft, and the pilot, who was the sole occupant, died at the scene.
The investigation
CENIPA investigators examined the aircraft, the site, and the pilot's operational history. Although the fire destroyed the aircraft's maintenance logs and flight reports, investigators confirmed the engine was operating at high power during the impact. The investigation found that the aircraft's airworthiness certificate was valid, and maintenance services had been performed appropriately. The meteorological conditions were favorable, with calm winds and a temperature of 28°C.
Regarding the airfield, the investigation established that the strip was clandestine and lacked essential safety infrastructure, such as a windsock, information on surface conditions, or a defined escape area. The strip was noted for having significant longitudinal and lateral unevenness and was situated near several hazards, including high-voltage power lines and trees.
Findings
- Lack of experience: The pilot had limited experience in agricultural flight operations, having only been engaged in his first harvest season for approximately two months.
- Operational errors: The pilot failed to account for critical obstacles, specifically wire fences and high-voltage lines positioned near the runway.
- Inadequate takeoff planning: The pilot did not adequately plan the takeoff to account for the runway's poor condition or the presence of obstacles, potentially opting for a low-altitude takeoff that did not utilize the aircraft's maximum performance capabilities.
- Deficient airfield supervision: The airstrip lacked minimum safety requirements, including sufficient separation between the runway end and obstacles, and lacked proper markings or wind indicators.
- Human factors: The pilot was at the end of a work shift, and the intense physical and emotional demands of agricultural operations may have contributed to fatigue or a lack of situational awareness.