What happened
On January 20, 2003, at approximately 17:30 local time, an EMB-201 aircraft, registration PT-GGD, was performing agricultural spraying operations at Fazenda Fornar in Espigão do Oeste, Rondônia. The aircraft was engaged in applying herbicide across the farm area.
During the takeoff roll, the aircraft struck a protective fence located at the end of the runway extension. The impact caused the aircraft to veer, strike a gate approximately 50 meters further along the runway alignment, and eventually capsize. The impact triggered a fire that consumed the aircraft. The pilot managed to egress from the wreckage but sustained severe burns over 80% of his body. Due to the remote location and lack of immediate medical infrastructure, the pilot required extensive transport through several cities before reaching a specialized burn center in Cuiabá, where he succumbed to his injuries two days later. The aircraft was destroyed.
The investigation
CENIPA's investigation revealed a series of critical irregularities regarding both the aircraft and the operational environment. The PT-GHD was operating with an expired Airworthiness Certificate, an overdue annual maintenance inspection, and expired mandatory insurance. Furthermore, the pilot was operating with an expired technical rating and an expired medical certificate.
Technical examination of the fuel system identified significant contamination. Fuel was being transported in reused plastic containers and transferred via 20-liter jugs, leading to the presence of foreign chemical substances in the fuel. The investigation also found that the fuel filter element was deformed due to excessive torque during maintenance, and the filter seal was worn and reused. Additionally, the runway at the private farm was unregularized, lacked proper markings, and featured high vegetation and standing water, which increased rolling resistance during the takeoff run.
Findings
- Improper maintenance practices, including the use of non-standard procedures like using thread seal tape on fuel filter connections and the reuse of worn seals.
- Fuel contamination resulting from inadequate handling and storage of fuel in non-aviation grade containers.
- Pilot physiological factors, as the pilot was recovering from malaria and was operating without adequate rest or nutrition.
- Poor decision-making, characterized by the pilot's decision to proceed with takeoff despite being aware of the high-risk runway conditions and the aircraft's heavy weight.
- Unsafe runway conditions, specifically the presence of an unmapped fence at the runway end and a muddy, unmaintained surface.
- Regulatory non-compliance, including the operation of an aircraft with expired documentation and the use of an uncertified private airstrip.