What happened
On February 17, 2001, an EMB-201A aircraft, registration PT-GTZ, was performing agricultural spraying operations over a farm in São Gabriel do Oeste, Mato Grosso do Sul. While the pilot was attempting to recover from a low-altitude pass, they successfully maneuvered to avoid a low-voltage power line positioned directly ahead of the flight path. However, the pilot failed to detect a second set of low-voltage lines running parallel to the aircraft's trajectory.
The right wing of the aircraft struck the parallel power lines, causing a loss of control. The aircraft's flight path shifted approximately 150 degrees to the right, leading to a collision with a cellular telephone antenna, followed by impacts with the tops of trees, before finally crashing into the ground. The aircraft sustained severe damage to the propeller, engine, fuselage, landing gear, and both wings. The pilot was able to exit the aircraft through the side window and escaped uninjured.
The investigation
CENIPA's investigation focused on the operational environment and the pilot's preparation. Investigators found that the pilot had not performed a prior reconnaissance of the area or a detailed study of a site map, leaving them unaware of the parallel power lines. The investigation also noted that the power lines involved were not marked with any visual markers or warning flags.
Human factors were a significant focus of the analysis. The pilot, while experienced and properly licensed, was experiencing chronic fatigue and reduced attention levels due to the intense workload and seasonal pressures of the agricultural spraying schedule. Furthermore, the investigation examined the role of the operator, Teruel Aviação Agrícola Ltda, regarding flight supervision and training standards.
Findings
- Lack of adequate flight planning, as the pilot did not conduct a pre-flight reconnaissance of the terrain or identify all obstacles.
- Inadequate supervision by the operator regarding flight planning and operational oversight.
- Unmarked power lines, as the low-voltage lines were not equipped with any visual markers to aid detection.
- Pilot fatigue and reduced alertness resulting from high workloads and the repetitive nature of the seasonal spraying schedule.
- Potential visibility issues caused by the possible poor condition or cleanliness of the aircraft's windshield.
Safety action
Following the investigation, several safety recommendations were issued in 2002:
- The operator was directed to re-evaluate its pilot training and recruitment systems, specifically focusing on flight planning and area reconnaissance.
- The operator was instructed to improve operational supervision and emphasize the importance of identifying and mapping obstacles.
- Regional aviation authorities (SERAC) were advised to notify power utility companies regarding the lack of marking on electrical lines to prevent future interference with agricultural flights.
- Maintenance protocols were highlighted to ensure windshield cleanliness for optimal external visibility.