What happened
On February 7, 2003, at approximately 09:30 AM, an EMB-201A Ipanessa, registration PT-GZW, was performing agricultural spraying operations over a rice plantation near Dourados, Mato Grosso do Sul. The aircraft departed from the Dourados aerodrome to service a field located roughly 4 nautical miles away. During a low-level spray pass, the aircraft struck three low-voltage power lines. Following the collision, the aircraft impacted the ground approximately 70 meters beyond the electrical infrastructure. The impact resulted in severe injuries to the pilot and extensive damage to the aircraft, including the engine, propeller, fuselage, wings, and various hydraulic and electrical systems. The collision also destroyed five utility poles.
The investigation
The CENIPA investigation focused on the pilot's transition to the aircraft type and the operational environment. Investigators found that while the aircraft's maintenance records were up to date and the pilot held a valid commercial license, the pilot had received no specific instruction or transition training for the EMB-201A Ipanema. The pilot's previous agricultural experience was primarily in the PA-18, a much smaller aircraft.
Environmental factors were also examined, noting that the low-voltage lines lacked any visible markers or warning signs. The pilot reported that intense sunlight was causing glare in his left eye, which may have impaired his visual field. Furthermore, the investigation noted a lack of ground support personnel (signalers) to assist with obstacle identification during the spray passes.
Findings
- Inadequate pilot transition: The pilot lacked specific training on the EMB-201A Ipanema, leading to a failure to account for the different aircraft dimensions and landing gear height compared to the PA-18.
- Operational errors: The pilot failed to perform adequate flight planning regarding terrain and obstacle height, and failed to execute a proper climb to clear the wires.
- Lack of supervision: The operator did not provide sufficient oversight or training for the pilot's first mission in this specific aircraft type.
- Environmental hazards: The absence of marking on the power lines and the presence of solar glare contributed to the difficulty in identifying the obstacle.
Safety action
- The investigation recommended that agricultural companies implement internal mechanisms to ensure pilots receive proper instruction and adaptation training for all aircraft types in their fleet.
- It was recommended that operators establish standardized flight planning procedures that account for terrain, obstacle height, and sun position.
- Regional aviation authorities were encouraged to promote the use of obstacle maps and to emphasize the importance of mission planning in agricultural flight schools.