What happened
On June 11, 2016, at approximately 16:37 UTC, a Grob G-103 glider, registration PT-PJE, was performing a local flight at the Aeroclube de Santa Catarina (SSKT) in São José, Brazil. The aircraft was carrying a pilot and one passenger.
During the landing phase, specifically while the pilot was performing the flare maneuver, the glider struck a person at the intersection of the runway and the taxiway leading to the hangars. The individual, a worker for a hangar tenant, was cleaning the area at the time. The impact caused the pilot to lose control of the aircraft, leading the left wingtip to strike the ground and forcing the glider off the left side of the runway. The aircraft sustained substantial damage. While the pilot and passenger were uninjured, the ground worker sustained serious injuries to the ribs and lungs due to the impact.
The investigation
CENIPA's investigation established that the worker had entered the runway area due to a moment of distraction and was not wearing a reflective vest or carrying a radio to monitor airfield communications. The investigation also noted that although the airfield had restricted access, there was a lack of rigorous control regarding the movement of people near the runway.
Furthermore, investigators examined the Aeroclube's Standard Operating Procedures (SOP). While a pre-flight briefing had been conducted, the investigation found that there was no active supervision of operations at the time of the accident, as personnel were focused on retrieving equipment near the runway head. The investigation also identified that the club's SOP lacked detailed specifications regarding the specific responsibilities and duties of various operational roles, such as the runway official and the instructor of the day.
Findings
- Inadequate supervision: There was a lack of management oversight regarding operational activities during the event.
- Organizational failures: The club's organizational processes and support systems were insufficient to ensure safety.
- Lack of personal protective equipment: The worker was not wearing high-visibility clothing or using communication equipment.
- Incomplete procedures: The existing SOPs did not clearly define the specific duties of personnel or provide enough detail to prevent operational errors.