What happened
On October 17, 2002, at approximately 04:40 UTC, a Cessna 208B, registration PT-MES, was preparing for a cargo flight from Guarulhos International Airport (SBGR) to Salvador (SBSV). Following the loading of cargo, the flight crew started the engines and established contact with ground control.
During this period, an INFRAERO ground employee, who was substituting for a regular staff member, approached the aircraft to deliver a necessary shipping document. Although the pilot had previously indicated that the document could be sent via fax, the employee attempted to hand-deliver it. As the crew noticed the individual approaching the engine and exhaust area, they attempted to warn him using hand gestures. However, the individual misinterpreted the signals, believing he needed to walk around the aircraft to reach the other side. In doing so, his left arm came into contact with the rotating propeller, resulting in serious injuries to the third party. The crew immediately shut down the engines and requested emergency medical services.
The investigation
CENIPA's investigation established that the aircraft was operating within weight and balance limits and that the crew was properly qualified and licensed. The investigation focused on the actions of the ground personnel and the operational environment at the time of the incident. It was noted that the employee was not familiar with the specific procedures of the ramp area, as his primary duties were located in the cargo warehouse. Furthermore, the investigation examined the visibility and auditory conditions at the time of the engine start-up.
Findings
- The primary contributing factor was the lack of adequate instruction for ground personnel regarding the specific risks of entering the maneuvering area and the dangers posed by moving aircraft components.
- The nighttime conditions, while the ramp was illuminated, likely made it difficult for the individual to perceive the rotation of the propeller.
- The use of hearing protection by the employee may have muffled the sound of the engine, further reducing his awareness of the aircraft's operational state.
- The absence of a ramp supervisor at the immediate location of the aircraft meant there was no oversight to prevent the unauthorized approach of the employee.