What happened
On November 8, 2003, an EMB 201 aircraft, registration PT-GVE, was performing agricultural spraying operations near Arroio Grande, Rio Grande do Sul. During the ninth takeoff of the day, while performing a left turn during the third spray pass, the engine failed without any prior warning or mechanical jolting.
The pilot attempted to manage the failure by advancing all throttles, but the engine did not regain power. The aircraft lost altitude and struck an uneven area of terrain, subsequently colliding with a tree and then another tree near a road. The impact caused the aircraft to rotate 13 and a half degrees on its vertical axis, leading to a post-crash fire that consumed the airframe. The pilot sustained severe injuries, including second-degree burns, after becoming trapped by the aircraft's structure during the attempt to evacuate through a window.
The investigation
CENIPA investigators examined the aircraft's maintenance history, the pilot's training, and the operational procedures of the operator. The investigation found that while the aircraft's maintenance was up to date, the aircraft was operating in a restricted category (up to 1,800 kg) despite its airworthiness certificate specifying a normal category (up to 1,550 kg).
Investigators also analyzed the pilot's response to the engine failure. It was noted that the pilot did not activate the electric auxiliary fuel pump, a procedure required by the manufacturer's manual, nor did he jettison the chemical load to reduce weight and drag. Furthermore, the investigation revealed a localized organizational culture where pilots routinely kept the auxiliary pump turned off to avoid potential engine flameouts and to reduce maintenance costs associated with the component's short service life.
Findings
- Pilot error and decision-making: The pilot failed to utilize available resources, such as the auxiliary fuel pump and the jettisoning of the spray load, to attempt to maintain flight or improve the glide ratio.
- Organizational culture: The operator's supervision was insufficient, as the company permitted a practice where pilots bypassed manufacturer-recommended procedures (specifically regarding the fuel pump) based on personal habits and cost-saving measures.
- Training gaps: There were indications of deficiencies in the pilot's training regarding emergency procedures and the specific use of the auxiliary fuel pump during agricultural applications.
- Psychological factors: The pilot's high self-esteem and overconfidence may have contributed to a failure to follow standard emergency checklists.
Safety action
Following the investigation, authorities were directed to conduct safety inspections of the flight school involved and the operating company to ensure compliance with manufacturer standards. Additionally, recommendations were made to coordinate large-scale industry events to address the growing number of accidents in agricultural aviation and to develop methods for evaluating in-flight operational proficiency.