What happened
On February 19, 1996, at approximately 17:30, an EMB-201 aircraft, registration PT-GIX, was performing agricultural spraying operations at Fazenda Oriental in São Desidério, Bahia. After completing the spraying mission, the pilot initiated a high-bank reversal maneuver at a low altitude. During this maneuver, the engine failed, causing the aircraft to lose altitude. The left wingtip struck the ground, leading to a subsequent rollover. The pilot sustained fatal injuries at the scene, and the aircraft was a total loss.
The investigation
CENIPA investigators examined the wreckage and the engine components. Technical analysis of the engine revealed that the starter motor's bendix remained engaged with the ring gear, indicating an unsuccessful attempt to restart the engine in flight. While the internal engine components, such as the cylinders, pistons, and lubrication system, were in good working order, the investigation identified critical failures in the ignition system. Specifically, the magneto wiring was found in a deplorable state, featuring makeshift repairs and silicone rubber insulation.
Furthermore, the investigation revealed that the aircraft's airworthiness certificate had been canceled because the annual maintenance inspection had been expired since June 1998. The investigation also noted that the pilot frequently performed aggressive maneuvers at low altitudes and often flew without a seatbelt. The operator's oversight was also scrutinized, as there was a lack of adequate maintenance tracking and flight hour monitoring.
Findings
- Engine failure due to inadequate electrical current in the magneto wiring caused by poor maintenance.
- Deficient maintenance, characterized by an expired annual inspection and improper repairs to the ignition cabling.
- Inadequate supervision by the operator, which failed to monitor maintenance schedules, pilot flight hours, or the execution of high-risk maneuvers.
- Human factors, specifically the pilot's tendency to perform aggressive, low-altitude maneuvers and a lack of risk consideration during the final phase of the mission.