What happened
On March 17, 1997, an Embraer E-201, registration PT-GXO, was being prepared for an agricultural spraying mission at Fazenda Taquaral in Planaltina, São Paulo. Due to a lack of radio contact with the ground coordination team, the pilot decided to take off to establish communication from a higher altitude.
After successfully establishing contact, the pilot entered the traffic pattern and began a sequence of aerobatic maneuvers, including several wingovers. During one of these maneuvers, the pilot attempted a wingover at an insufficient altitude to recover to level flight, resulting in a 90-degree impact with the ground. The impact caused the fatal death of the pilot and the total loss of the aircraft.
The investigation
The CENIPA investigation established that the pilot, while a qualified commercial pilot for agricultural operations, was performing maneuvers for which they were not specifically qualified or rated. The investigation found that the pilot frequently performed low-altitude aerobatics despite warnings from colleagues regarding the inherent risks.
Furthermore, the investigation revealed that the aircraft was being used for maneuvers that contradicted the manufacturer's operational limitations. The investigation also noted significant maintenance and regulatory lapses, including expired technical ratings for the pilot, an expired medical certificate, and overdue periodic maintenance inspections for the aircraft. The investigation ruled out engine failure or mechanical malfunction as the cause of the impact.
Findings
- Flight Indiscipline: The pilot intentionally disregarded operational regulations and aircraft limitations by performing unauthorized aerobatic maneuvers in an agricultural aircraft.
- Inadequate Supervision: The operator failed to provide effective oversight, allowing the pilot to operate with expired technical qualifications and permitting unsafe flight practices.
- Excessive Self-Confidence: The pilot demonstrated a pattern of performing high-risk maneuvers at low altitudes, driven by excessive confidence in their psychomotor skills.
Safety action
- The operator, Melhor Aviação Agrícola Ltda, was directed to ensure all fleet maintenance inspections are performed by approved workshops and to implement stricter controls over crew qualifications.
- The operator was instructed to implement educational programs regarding operational professionalism and flight safety.
- Local aviation authorities (SERAC) were tasked with conducting a safety inspection of the company to mitigate identified risks.