What happened
On May 7, 2003, an EMB 202 aircraft, registered as PT-ULF, was performing agricultural spraying operations over a cotton plantation at Fazenda Itaquerê, near Novo São Joaquim, Mato Grosso. During the reversal maneuver of the final pass of the morning session, the aircraft lost altitude while aligning for a new spray run. The aircraft entered the cotton crop, flying approximately 100 meters within the vegetation before striking the ground and impacting heavily. The impact caused the cockpit and tail cone to catch fire. The pilot sustained minor injuries, while the aircraft suffered extensive damage to the fuselage, cockpit, electrical systems, engine, and landing gear.
The investigation
CENIPA investigators examined the engine and propeller, finding no evidence of mechanical failure prior to the impact. Tests revealed that the engine power had been cut via the throttles before the crash. The investigation also reviewed the pilot's medical history and operational conditions. The pilot had been flying since 1979 and was highly experienced, with approximately 12,000 flight hours in this aircraft type. At the time of the accident, the pilot had been working since 06:30 and had been on duty for five hours. The investigation also focused on the ergonomic placement of the Differential Global Positioning System (DGPS) used for precision spraying, which was located low on the instrument panel.
Findings
- Loss of situational awareness due to the pilot's excessive concentration on the DGPS, which required looking away from external visual references.
- Psychological and physiological stress, potentially caused by an intense workload, fatigue from the seasonal spraying schedule, and the pilot's use of unmonitored medication for blood pressure control.
- Ergonomic issues related to the DGPS installation, which may have diverted the pilot's attention inside the cockpit during a critical phase of flight.
- Inadequate operational supervision regarding the monitoring of pilot fatigue and medical health within the company.