What happened
On November 27, 2000, an EMB 201A aircraft, registration PT-UBA, operated by Patruaar Serviços Agrícolas Ltda, was performing crop dusting operations over a rice paddy in Capão do Leão, Rio Grande do Sul. The mission involved spraying the field using a ground signalman (known locally as a "bandeirinha") to mark the flight path.
During the seventh pass of the operation, the pilot initiated a climb after completing a spray run. During this maneuver, the aircraft experienced a light impact. The pilot initially suspected a bird strike but subsequently discovered that the aircraft had struck the ground signalman, who was positioned on an elevated road perpendicular to the flight path. The pilot immediately requested medical assistance for the signalman and returned to the airfield to land. While the aircraft sustained no damage, the signalman sustained fatal injuries at the scene.
The investigation
CENIPA's investigation focused on the operational procedures and the training of ground personnel. The pilot was highly experienced, with 10,00 and 9,500 hours in this specific aircraft type, and held all necessary valid certifications. Meteorological conditions were favorable for visual flight.
The investigation examined the role of the signalman, who was selected from available farm workers without specific training. It was noted that the signalman was positioned on a road that sat higher than the surrounding field, placing him within the aircraft's flight path. Investigators also looked into the possibility of physiological factors affecting the signalman's alertness, noting unconfirmed suspicions that the individual had attended a social event the previous night and may have been fatigued or under the influence of alcohol.
Findings
- Improper positioning of ground personnel: The signalman failed to clear the aircraft's flight path, either by remaining in the path or returning to it after the aircraft had aligned for the pass.
- Lack of specialized training: There was no formal training or safety instruction provided to the signalmen, who were chosen at random from farm staff.
- Deficient supervision: The operator failed to implement clear procedures or oversight to ensure signalmen understood the necessity of staying clear of the aircraft's trajectory.
- Inadequate safety culture: The organizational structure lacked a prevention-oriented culture regarding the risks of ground signaling.
- Pilot judgment: The pilot assumed the signalman had already cleared the axis of the flight path before the collision occurred.