What happened
On March 6, 2015, at approximately 21:00 UTC, an agricultural operation was underway at Fazenda Sete Lagoas in Mogi Guaçu, São Paulo. The aircraft, a Neiva EMB-202A registered as PT-VTW, had recently landed to undergo refueling of both fuel and agricultural chemicals for its final mission of the day.
During the refueling process, another aircraft, a PT-VVU, landed and positioned itself approximately 10 meters ahead of the PT-VTW. After completing the chemical replenishment, the pilot of the PT-VTW exited the cockpit via the right wing trailing edge. As the pilot walked toward the aircraft positioned ahead, he entered the arc of the PT-VTW's propeller, which was still running at idle speed. The propeller blade struck the pilot's head, resulting in fatal injuries. Ground personnel immediately shut down the engine and provided first aid, but the pilot was pronounced dead at the scene.
The investigation
CENIPA's investigation established that the pilot was highly experienced, with approximately 1,200 flight hours, 750 of which were in the Ipanema aircraft family. The pilot held valid commercial licenses and medical certification. The PT-VTW was also found to be airworthy, with a valid maintenance certificate and within weight and balance limits.
The investigation focused on the operational environment and the sequence of movements. Investigators noted that the sun was near the horizon, which had begun to degrade natural visibility. Furthermore, the investigation examined the practice of refueling with the engine running. While regulations at the time allowed for certain refueling procedures with the engine at idle, the pilot's decision to abandon the cockpit while the engine was still operational was a critical point of scrutiny.
Findings
- The pilot's movement toward the leading aircraft likely caused him to lose track of his distance from the propeller arc.
- Diminished visibility due to the proximity to sunset likely hindered the pilot's ability to perceive the moving propeller.
- The operation exhibited an organizational culture of low adherence to safety standards, characterized by excessive informality.
- The pilot abandoned the cockpit while the engine was still running, which deviated from established safety practices and flight manuals.
- The lack of adequate managerial supervision contributed to the unsafe ground procedures.