What happened
On January 28, 1996, at approximately 10:00 AM, an EMB-201 Ipanema, registration PT-GPD, was performing agricultural spraying operations over a soybean field at Fazenda Seleme, near Palotina, Paraná. The aircraft was operating for COOPERVALE on a local mission.
During the second spray pass, which was being conducted in an east-west direction, the pilot exceeded the flight boundaries marked by flags. The aircraft struck a rural electrical power line at an altitude of approximately 7 meters. The impact caused significant damage to the left horizontal stabilizer and elevator. Following the initial collision, the aircraft struck the treetops and subsequently crashed into the ground. The pilot sustained fatal injuries, including head trauma and chest crushing, caused in part by the failure of the seat harness and suspenders during the impact.
The investigation
CENIPA's investigation focused on the operational environment and the pilot's decision-making process. The investigation established that the aircraft was well-maintained, with all inspections up to date, and was operating within its approved weight and center of gravity limits. The pilot was highly experienced and qualified for the mission.
Investigators examined the lack of detailed mission planning tools, noting that no grid maps or sketches of the area were provided to the pilot. The briefing for the mission was conducted solely via radio with an agricultural technician, rather than through a formal ground-based briefing with the full team. Furthermore, the investigation looked into the environmental conditions, specifically how the morning sun, combined with the dark green vegetation, may have caused glare and obscured the visibility of the power lines.
Findings
- Inadequate Supervision: The operator failed to provide sufficient operational oversight or necessary planning data, such as maps of the area's obstacles, leaving the pilot with excessive responsibility for hazard identification.
- Deficient Planning: The mission briefing was insufficient, as it was conducted via radio rather than in person, and lacked a detailed review of terrain obstacles.
- Human Factors: The pilot's psychological profile—characterized by a high degree of skill and previous experience in the same area—led to an overreliance on past perceptions and a failure to correctly assess the risks of the current flight path.
- Environmental Factors: The sun's position and the contrast with the vegetation likely contributed to the pilot's inability to perceive the electrical wires.
- Equipment Failure: While not the cause of the collision, the detachment of the safety harness and the breakage of the suspenders during the impact significantly contributed to the severity of the pilot's injuries.