What happened
On June 1, 2003, at approximately 08:00Q, an EMB-201A performing agricultural spraying operations at Fazenda Guanabara, near Nova Olímpia, Mato Grosso, experienced a sudden loss of engine power. The aircraft, registered as PT-UCZ, was conducting its second flight of the day, applying pesticides to a sugarcane plantation.
Following the loss of power, the pilot attempted emergency restart procedures, including switching fuel tanks, but the engine failed to respond and began to vibrate significantly. Given the low altitude of the operation, the pilot executed emergency procedures by jettisoning the 500-liter pesticide load, shutting off the fuel selector, and cutting the magnetos and battery. The aircraft then performed a forced landing in a sugarcane field. The impact resulted in severe damage to the airframe, though the pilot sustained only minor injuries.
The investigation
CENIPA investigators examined the engine, propeller, electrical system, and lubrication system. Analysis of the propeller indicated that the engine was not producing power at the moment of impact. While the mechanical components of the engine and fuel system showed no definitive signs of failure, investigators noted corrosion on the engine mount.
The investigation also uncovered significant maintenance record irregularities. Although the aircraft's maintenance was reportedly up to date, several key logs were outdated or incomplete. Specifically, a major engine overhaul (TBO) performed in April 2002 was not recorded in the engine logbook, and the propeller's maintenance history could not be verified due to incomplete documentation. Additionally, the aircraft's alternator lacked proper identification.
Findings
- Deficient Maintenance Oversight: Irregularities in maintenance records and the lack of a dedicated maintenance department created uncertainty regarding the quality of previous services.
- Lack of Supervision: The pilot acted as the sole person responsible for all aviation-related aspects of the operation, leaving him without technical oversight or a point of reference for technical queries.
- Operational Risks: There were indications that the auxiliary fuel pump (booster) might not have been engaged during the spraying operation, as required by the aircraft's operating manual. The pilot's low-altitude flight profile left very little time to diagnose and rectify the engine power loss.
Safety action
- The regional aviation authority (SERAC 6) was directed to disseminate the report's findings through seminars and lectures focused on agricultural aviation, emphasizing the need for maintenance supervision and specialized emergency training.
- The operator, Itamarati Norte S/A Agropecuária, was instructed to implement an infrastructure of support for its aerial activities to reduce the pilot's workload and increase oversight of aircraft maintenance.