What happened
On March 2, 2004, at approximately 09:30 local time, a Piper PA-25-235, registration PT-OPS, departed from Fazenda Savana for a short 25 km transit flight to Fazenda Pôr-do-sol in Guarda Mor, Minas Gerais. The mission was part of routine agricultural operations for Aerominas Aviação Agrícola Ltda.
Shortly after takeoff, the aircraft encountered rapidly deteriorating weather conditions. While the pilot attempted to maintain visual contact with the ground by flying close to the treetops, a dense fog descended. The aircraft eventually entered Instrument Meteorological Conditions (IMC), despite not being equipped for instrument flight. The aircraft struck the ground at a steep 40-degree nose-down attitude, resulting in the death of the pilot and the total destruction of the aircraft.
The investigation
CENIPA's investigation focused on the pilot's decision-making and the environmental factors present at the time of the accident. The investigation established that the pilot was relatively inexperienced in agricultural aviation, having only 65 hours of flight time in this specific model. Furthermore, the pilot's medical certificate (CCF) had expired.
Investigators examined the meteorological conditions, noting that the region is prone to rapid weather changes due to the condensation of warm, moist air over the plateau. While a nearby pilot successfully landed an aircraft at an alternative strip before the fog arrived, the pilot of PT-OPS continued the flight. The investigation also looked into the operational pressures, noting that the pilot may have felt motivated to complete the transit to ensure the aircraft was refueled and ready for the next spraying mission as soon as possible.
Findings
- The primary cause of the accident was spatial disorientation induced by the sudden onset of dense fog and low visibility.
- The pilot's decision-making was compromised by high motivation to complete the mission, leading to a departure in weather conditions below VFR minimums.
- The pilot lacked the necessary experience in agricultural operations and the specific aircraft type to manage the sudden loss of visual references.
- The aircraft was not equipped with the necessary instruments for flight in IMC.
- The pilot failed to plan for an alternative landing site or consider the rapidly changing local meteorology.
- The pilot's medical certificate was expired at the time of the flight.