What happened
On January 4, 1996, an Embraer EMB 201A agricultural aircraft, registration PT-GVA, was returning to the Bossoroca airfield in Rio Grande do Sul, Brazil, after performing crop dusting operations approximately 10 km away. The aircraft was carrying the pilot and one passenger.
During the final approach to runway 10, the aircraft entered a stall at a very low altitude. The pilot attempted to maintain the approach despite significant wind conditions, but the aircraft struck the ground violently. The impact resulted in the two fatalities of both occupants and the total destruction of the aircraft.
The investigation
CENIPA's investigation focused on the aircraft's configuration and the pilot's operational compliance. Investigators determined that the aircraft was being operated outside of its certified parameters. Although the engine and propeller maintenance records were up to date, the aircraft was carrying a passenger, which contradicted the manufacturer's single-occupant limitation. This extra weight shifted the Center of Gravity (CG) to 30.8%, which was beyond the established limit of 27% aft.
Analysis of the wreckage showed the engine was at maximum power at the moment of impact. Investigators noted that the pilot was performing a high-bank turn (approximately 90 degrees) during the base-to-final transition at an altitude of only 100 feet. Given the 16-knot wind with gusts, the aircraft's airspeed was likely near the stall speed. Furthermore, the investigation revealed that the pilot was flying with expired commercial and agricultural licenses, as well as an expired medical certificate.
Findings
- Improper Weight and Balance: The unauthorized transport of a passenger caused the CG to shift 3.8% beyond the aft limit, compromising aerodynamic stability.
- Low Altitude Maneuvering: The pilot conducted the approach at an extremely low altitude of 100 feet, which prevented any possibility of recovering from the stall.
- Adverse Weather: Strong winds and gusts contributed to an unstable approach and an improper flight path.
- Operational Non-compliance: The pilot intentionally disregarded flight regulations, including flying with expired certifications and operating the aircraft outside its approved envelope.
- Organizational Oversight: The operator failed to supervise flight operations effectively, allowing the pilot to continue practicing unsafe, non-standardized procedures and carrying unauthorized passengers.