What happened
On February 12, 2014, a Neiva EMB-201, registration PT-GEZ, was positioned at an agricultural landing site at Fazenda Nossa Senhora de Fátima in Chapadão do Sul, Mato Grosso do Sul, for refueling and chemical replenishment. The aircraft was being prepared for agricultural spraying operations.
During the startup sequence, the pilot activated the engine while the aircraft's wheel chocks were still in place. Noticing this, a company employee approached the aircraft to remove the chocks. After removing the blocks, the worker moved toward the front of the aircraft rather than following the established safety path along the wing. In doing so, the individual entered the propeller's arc and was struck in the face and right arm by the rotating blades. The worker was transported to a local hospital and later transferred to Campo Grande, where they succumbed to their injuries on February 14, 2014. The pilot remained uninjured, and the aircraft sustained no damage.
The investigation
CENIPA's investigation confirmed that the pilot was fully qualified with valid medical and aeronautical certifications, and the aircraft was airworthy, properly balanced, and maintained. Meteorological conditions were favorable for flight operations.
The investigation focused on the actions of the ground personnel and the company's safety management. While the operator claimed that employees were instructed to approach aircraft only from the side, near the trailing edge of the wing, the investigation found no evidence of a formal training program or records of safety training for ground staff. The investigation noted that because the task of removing chocks was not a routine part of the worker's daily duties, they were not habituated to the specific safety sequence required when an engine is running.
Findings
- Lack of formal training: The agricultural operator lacked a documented training program to ensure ground personnel were familiar with safe approach and departure paths near active aircraft.
- Inadequate managerial supervision: There was a lack of oversight regarding the planning and execution of ground activities and the verification of personnel competence.
- Improper movement: The worker's path toward the front of the aircraft placed them directly in the propeller's path during engine operation.
Safety action
CENIPA issued the following recommendations to the National Civil Aviation Agency (ANAC):
- Require mandatory safety familiarization training for all employees of agricultural aviation companies who work near operational areas.
- Mandate that agricultural aviation companies maintain strict control and records of employee training to ensure only qualified personnel perform ground tasks.
- Evaluate the feasibility of requiring formal, written records of all safety training contents and objectives within the regulatory framework (RBAC 137).