ASN Wikibase Occurrence # 186037
This information is added by users of ASN. Neither ASN nor the Flight Safety Foundation are responsible for the completeness or correctness of this information.
If you feel this information is incomplete or incorrect, you can submit corrected information.
| Date: | Wednesday 30 March 2016 |
| Time: | 06:50 LT |
| Type: |  Piper PA-25-235 Pawnee |
| Owner/operator: | Banalves Aviação Agrícola Ltda |
| Registration: | PR-SRM |
| MSN: | 25-3710 |
| Year of manufacture: | 1965 |
| Fatalities: | Fatalities: 0 / Occupants: 1 |
| Other fatalities: | 1 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Luiz Alves, Santa Catarina -
 Brazil
|
| Phase: | Manoeuvring (airshow, firefighting, ag.ops.) |
| Nature: | Agricultural |
| Departure airport: | Luiz Alves, Santa Catarina |
| Luiz Alves, Santa Catarina | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
A crop duster PR-SRM collided with another crop duster PR-WKK. After the collision the PR-SRM made the landing normally, with damage to the aircraft, and other PR-WKK plane crashed in banana plantation. The pilot of the plane PR-WKK died on the spot.
Contributing factors.
- Attention - undetermined.
It is possible that there have been failures of attention on the part of the pilots, leading them not to identify the proximity of the other aircraft in good time to avoid the collision.
- Task characteristics - undetermined.
The characteristics of agricultural aviation, which require expertise and attention from the pilot, combined with the characteristics of the operation in the region of the accident, configured a context of high operational risk. The complexity involved in the task, coupled with the demand to be executed under time pressure, may have favoured failures in the pilots' perception and, consequently, led to the collision of the aircraft.
- Organizational climate - undetermined.
The posture of the managing partner towards the other employees harmed the relationships established between the members of the organization. This situation was configured as a latent failure that may have contributed to the occurrence, since it discouraged dialogue, even if there were doubts about the operation. There was, therefore, an unfavorable organizational climate, as facts and practices related to flight safety issues were not properly reported.
- Communication - contributed.
There were no daily briefings between members of the organisation and no Banalves aircraft had VHF radio or any other type of communication equipment to coordinate the flights that were being conducted.
In the on-screen accident, these conditions did not allow the pilots involved in the occurrence to know each other's positions, as well as making communication between aircraft after take-off impossible. Failures in this communication process contributed to the accident.
- Organizational culture - undetermined.
In the organizational context, the relationships established were impaired, making communication between members difficult. There was no reporting culture and employees tried not to expose themselves. Also, practices considered unsafe to the operation were accepted. These facts indicated the existence of a fragile culture regarding the maintenance of acceptable levels of flight safety, which may have contributed to the occurrence.
- Working group culture - undetermined.
Pilots were not in the habit of using maps as consultation material during the flights, as the use of this resource was considered an admission of lack of preparation. This practice, which may have contributed to the accident, was reinforced by the administrator himself, also a pilot of the PR-WKK aircraft involved in the occurrence.
- Flight planning - contributed.
The pilots' lack of knowledge of the information regarding the mapping of the region to be sprayed, such as: lateral limits, obstacles and proximity between crops, made it impossible for the crew members to keep high situational awareness about the dangers of a possible collision.
- Perception - undetermined.
Pilot familiarization with the presence of nearby aircraft, failures in organizational processes regarding flight planning support and work supervision, as well as communication unfeasibility may have
contributed to the lowering of the pilots' level of situational awareness. On screen occurrence, such elements may have favored situational awareness failures, which contributed to the aircraft collision.
- Management planning - contributed.
The company did not provide the maps for pilot consultation. In addition, there was no updating and addition of information such as: obstacles installed, modification of the crop boundaries and the name of neighboring properties. The crew members took off only with the coordinates information preloaded in DGPS, without the knowledge of the obstacles and the areas that were being sprayed simultaneously in their vicinity.
- Organisational processes - undetermined.
The flight schedule and the availability of information concerning operations were carried out informally. There was no adequate organisational support for the execution of operational activities, such as briefings and updated support materials.
The absence of these practices denounced failures in the management and supervision of the work, since there was no effective control over the activities being executed or adequate management of the risks involved in the operations, which may have contributed to the occurrence on screen.
- Management supervision - contributed.
The owner of the company who was also a pilot was not concerned with conducting a briefing at the beginning of daily operations with the other pilots.
Such action would clarify which crops would be sprayed, thus reducing the possibility of nearby areas being flown simultaneously, mitigating the possibility of conflict between two or more aircraft.
Allowing pilots, deliberately and without plausible reasons, to refuse to participate in recycling activities or raising the level of knowledge, in the interest of operational safety, showed a failure in the assumption of a high level of safety.
Accident investigation:
 |
|
Sources:
http://g1.globo.com/sc/santa-catarina/noticia/2016/03/dois-avioes-agricolas-batem-no-ar-e-um-piloto-morre-em-santa-catarina.html
http://www.noticiasaominuto.com.br/brasil/204468/piloto-morre-apos-colisao-de-avioes-agricolas-em-sc
http://jornaldesantacatarina.clicrbs.com.br/sc/geral/noticia/2016/03/piloto-morre-em-queda-de-aviao-agricola-em-luiz-alves-no-vale-do-itajai-5612910.html
https://sistemas.anac.gov.br/aeronaves/cons_rab.asp?nf=PRSRM
https://sistemas.anac.gov.br/aeronaves/cons_rab.asp?nf=PRWKK
http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/pt/PR-SRM_-_PR-WKK_30_03_2016-AC.pdf
History of this aircraft
Other occurrences involving this aircraft
| 29 February 2012 | PR-SRM | Luiz Alves, SC | |
unk |
Media:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 31-Mar-2016 05:46 | cleberjc | Added |
| 31-Mar-2016 05:46 | harro | Updated [Aircraft type] |
| 23-May-2020 19:02 | KagurazakaHanayo | Updated [Source, Narrative] |
| 23-May-2020 19:03 | harro | Updated [Narrative] |
| 23-May-2020 19:04 | harro | Updated [Narrative, Accident report, ] |
Corrections or additions? ... Edit this accident description
The Aviation Safety Network is an exclusive service provided by:
Quick Links:
| ASN Home | Send Correction / Feedback |
| FSF Home | Disclaimer | Copyright |
| Contact Us | Privacy Policy |
| Press / Media |
CONNECT WITH US:
©2024 Flight Safety Foundation