What happened
On November 9, 2010, a Cirrus SR20, registration PR-REI, was performing a takeoff from a decommissioned landing strip in Andaraí, Bahia. The strip was not a registered or certified aerodrome, but rather a public road used by vehicles and pedestrians.
The pilot had previously performed a precautionary landing at this location due to observed fluctuations in engine oil pressure and temperature. After remaining on the ground for approximately three and a half hours to inspect the engine, the pilot attempted to depart. During the takeoff roll, the aircraft collided with a child who was running on a trajectory that converged with the aircraft's path.
Following the impact, the aircraft experienced a strong left yaw and indicated a pre-stall speed. The pilot continued the takeoff and flew approximately 120km to the Itaberaba aerodrome, where the aircraft eventually landed. The collision resulted in one fatality (the child) and significant damage to the aircraft, including the loss of the pitot tube and damage to the left wing leading edge. The pilot and three passengers were uninjured.
The investigation
CENIPA's investigation focused on the decision-making process and the operational environment of the takeoff. Investigators examined the status of the aircraft, finding that the SR20 was within weight and balance limits and had valid airworthiness certification.
The investigation also reviewed the pilot's actions regarding the use of an unauthorized landing site. While the pilot reported a mechanical concern that prompted the landing, investigators noted that several certified aerodromes with adequate infrastructure, such as Mucugê and Lençóis, were within close proximity. Furthermore, the investigation looked into the lack of perimeter control at the takeoff site, as the area was a public thoroughfare with no isolation from pedestrians.
Findings
- The pilot's attention was focused on internal engine parameters and airspeed during the takeoff roll, which prevented the detection of external hazards.
- There was a lack of situational awareness regarding the risks of operating from a public road where pedestrians and vehicles are present.
- The pilot failed to implement necessary measures to isolate the takeoff area from the public.
- The decision-making process was flawed, as the pilot chose to land at an uncertified site rather than proceeding to a nearby qualified aerodrome despite the reported oil pressure fluctuations.
- The aircraft owner, who was on board, did not intervene to mitigate the risks associated with the unauthorized landing and takeoff.