What happened
On September 27, 1999, a PA-25-235 operated by Aero Agrícola Caiçlar Ltda. was performing agricultural spraying operations over a banana plantation at Fazenda Irmãos Tavares, located in Sete Barras, São Paulo. The aircraft had departed from the Registro aerodrome to apply pesticides to the crops.
During the first pass of the application mission, the aircraft collided with a pole belonging to a low-voltage electrical network that crossed the plantation. The impact was violent, causing the aircraft to sustain severe damage that rendered it a total loss. The pilot sustained fatal injuries at the scene.
The investigation
CENIPA investigators established that the electrical network had been installed in the area in April 1999. Although the pilot had previously flown in the area after the installation and was aware of the infrastructure, the power lines lacked any visible markers or warning flags. The terrain in the application area was irregular, featuring elevations that increased the pilot's workload and complicated visibility.
The investigation also identified that the aircraft was equipped with an automotive battery and voltage regulator, components that were not certified for aviation use. Furthermore, the investigation looked into the operational procedures of the operator, noting that the pilot had not performed a pre-flight area reconnaissance, had not created a flight sketch (croqui), and had not conducted a mission briefing with ground support personnel prior to the flight.
Findings
- Deficient Flight Planning: The lack of area reconnaissance, mission sketches, and ground briefings made it difficult to identify and maintain awareness of the electrical hazards.
- Environmental Factors: The irregular topography of the plantation and the lack of marking/flagging on the power lines contributed to the difficulty in detecting the obstacle.
- Inadequate Training and Supervision: The operator's training programs failed to standardize essential flight planning procedures, and the company's supervision was insufficient to ensure safety compliance.
- Organizational Culture: Evidence of complacency and a lack of adherence to safety standards was noted, including the use of non-certified automotive parts in the aircraft.
Safety action
CENIPA issued several recommendations to Aero Agrícola Caiçara, including the mandatory dissemination of the accident report to all pilots, a re-evaluation of the company's training program to ensure standardized planning, and a review of maintenance and operational supervision processes. Additionally, the SERAC 4 was tasked with conducting a special flight safety inspection of the operator.