What happened
On November 7, 2001, at approximately 11:05 AM, two agricultural aircraft, PT-UMC (an EMB 202) and PT-UCS (an EMB 201A), were performing simultaneous pesticide spraying operations over a soybean plantation at Fazenda Santa Isabel, near Itiquira, Mato Grosso. The two aircraft were operating in adjacent, perpendicular flight paths that shared a common turnaround area.
During the final pass of the day, the pilot of PT-</strong>UMC, having completed the spraying run and being empty of product, performed a turn in the opposite direction of the established standard procedure. This maneuver caused the left wing of PT-UMC to strike the engine and propeller of PT-UCS from below. The impact caused the pilot of PT-UMC to lose control, leading to a fatal crash into the ground. The pilot of PT-UMC died at the scene, and the aircraft was destroyed. The pilot of PT-UCS managed to maintain control of the aircraft despite damage to the propeller and engine cowling, successfully landing at the farm's airstrip.
The investigation
CENIPA's investigation focused on the operational environment and the human factors involved in the collision. The investigation established that both pilots were experienced and held valid commercial licenses, although their IFR certifications had expired. The aircraft maintenance records for both planes were found to be up to date and adequate.
Investigators examined the organizational practices of the operator, Agroer Aviação Agrícal, finding that the company had failed to conduct an operational briefing (briefing) prior to the mission. Because the operation was considered "routine," no specific coordination was established for the shared turnaround area. Furthermore, the investigation looked into the physiological state of the pilot of PT-UMC, noting that he had recently returned to flight duties after a six-month hiatus and was reportedly using antidepressant medication, a fact known to the company but not addressed in terms of flight safety risks.
Findings
- Inadequate operational planning: The lack of a pre-flight briefing meant there were no established procedures for navigating the common turnaround area, leading to a reliance on assumptions rather than coordinated instructions.
- Pilot error: The pilot of PT-UMC miscalculated his position relative to the other aircraft and executed an improper turn.
- Organizational failure: The company failed to implement a systematic process for monitoring the psychophysiological health of its pilots, specifically regarding the use of controlled medications.
- Lack of retraining: The pilot of PT-UMC had only performed two hours of readjustment flight time following a long period of inactivity, which may have contributed to the error.
- Operational complacency: Both the pilots and the technical-operational sector of the company accepted the lack of briefings as a normal part of the work routine.