What happened
On December 12, 2005, at the São Lourenço Farm airfield in Corumbá, Mato Grosso, a Cessna 172, registration PT-JKA, was involved in a fatal ground accident. The pilot had prepared the aircraft for a flight to Campo Grande to transport two passengers. After moving the aircraft from its hangar to the taxiway, the pilot started the engine to allow it to warm up.
While the engine was running, the pilot left the aircraft unattended to walk to a nearby residence to summon the passengers. During the boarding process, a passenger approached the aircraft from the rear. While attempting to walk around the left side of the aircraft to reach the pilot's door, the passenger collided with the rotating propeller. The impact resulted in one fatality.
The investigation
CENIPA's investigation established that the pilot had left the engine running and the aircraft unattended while retrieving passengers. The investigation noted that a nearby power generator was operating at the time, creating significant noise that may have contributed to the passenger's inability to perceive the moving propeller.
Investigators found that the victim had never flown in an aircraft before and had not received any safety briefing or instructions regarding boarding procedures. Additionally, while the pilot was experienced, the investigation revealed that the aircraft's maintenance logs for the engine, propeller, and airframe were outdated, and the flight log had not been properly updated to reflect the aircraft's recent movement to the farm.
Findings
- The pilot's decision to leave the engine running while unattended and without supervising the boarding process.
- The lack of a safety briefing for the passengers, specifically for the individual who was a first-time flyer.
- High ambient noise levels from a nearby generator that likely masked the sound of the engine.
- An organizational culture of non-compliance, evidenced by the pilot's disregard for standard operating procedures and the owner's lack of operational oversight.
- The pilot's failure to properly assess the risks associated with unaccompanied boarding.