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Accident investigation report completed and information captured
Narrative: An agricultural plane crashes on a Volkswagen Kombi Transporter, with several passengers around 17h on Wednesday (20) on the highway Carlos João Strass, the Warta district of Londrina, Northern Paraná, and left 6 dead and two in serious condition. The pilot sustained injuries without the risk of life
3.2 Contributing factors. - Control skills – a contributor. The performance of a return curve to the runway outside the flight envelope contributed to the loss of control of the aircraft. - Piloting judgment – a contributor. Despite being out of the envelope to perform a return to the runway, the pilot thought that he could carry out such a procedure, thus contributing to the loss of effectiveness of flying commands. - Aircraft maintenance – undetermined. The technical analysis found that the engine failure that equipped the AT-401B PT-WFX aircraft was caused by a fatigue of material that caused two passing cracks, which propagated to the head of cylinder #4, causing it to fail due to deficiency in compressing the air-fuel mixture in the combustion chamber. However, it was not possible to determine, objectively, if there was any deficiency in the engine revision services and in the identification of this fatigue, leaving the contribution of this factor indeterminate. - Motivation – undetermined. It is possible that the adoption of subjective criteria in the decision-making process during the emergency, to the detriment of compliance with the prevised procedures, has been influenced by the motivation of the pilot to be stabilized in the company. - Insufficient pilot’s experience – undetermined. The pilot was more experienced at another type of equipment and only had 30 hours of flight time on the crashed aircraft model, which may have influenced his ability to evaluate the performance of the AT-401B, especially in an in-flight engine failure condition. - Decision-making process – a contributor. The decision to return to the runway for landing was based on an inadequate assessment of the operational conditions present at the time of the emergency and the fear generated by the possibility of personal injury risk, considerable damage to the aircraft and loss of credibility with employers. The adoption of these subjective criteria led to an unfavorable decision to the context of the emergency and contributed to the occurrence. - Managerial oversight – undetermined. Although it was not possible to point out the maintenance of the aircraft as a contributing factor in this accident, it was verified that there were company failures in the monitoring and supervising of these services, since the airframe, engine and propeller logbooks were outdated, as well as there was no record of the last 1.000 hour revision of the aircraft. Such failures of supervision may have allowed the fatigue process on cylinder #4 to pass unnoticed. - Other – a contributor. The fact of not wearing flight gloves resulted in burning injury to the hands, which could have been avoided or minimized with the use of this Individual Protection Equipment (EPI).