What happened
On September 2, 2022, at approximately 11:40 UTC, an Aero Bravo 700, registration PU-JJR, was prepared for a private flight at Ministro Victor Konder Airport (SBNF) in Navegantes, Brazil. The pilot intended to fly to Brusque, SC.
During the pre-flight phase, the pilot attempted to start the engine but was unsuccessful. Suspecting that the mixture control had caused an excess of fuel to accumulate in the engine, the pilot decided to inspect the engine. Relying on his experience as an aircraft mechanic, the pilot exited the cockpit to manually rotate the propeller to clear the excess fuel.
Crucially, the pilot failed to perform the engine shutdown procedure before exiting the aircraft, leaving the magnetos in the 'on' position. As the pilot manually turned the propeller, the engine unexpectedly ignited. While attempting to rush back to the cockpit to shut down the engine, the pilot was struck by the moving propeller blades.
The investigation
CENIPA's investigation confirmed that the pilot held valid commercial and single-engine land licenses, as well as a valid medical certificate. The aircraft's airworthiness certificate was also up to date. The investigation established that the pilot's actions—performing maintenance-related tasks without proper authorization and failing to follow standard shutdown procedures—demonstrated a lack of situational awareness.
Investigators noted that the pilot's motivation to stay on schedule for the day's planned flight instructions likely influenced his decision-making. Furthermore, when the engine unexpectedly started, the pilot may have experienced "tunnel vision," focusing on the risk of the aircraft moving and neglecting his proximity to the rotating propeller blades.
Findings
- The pilot exited the aircraft without performing the required engine shutdown procedure, leaving the magnetos active.
- The engine started unexpectedly during manual propeller rotation.
- The pilot sustained serious injuries to his left arm and back.
- The Aero Bravo 700 sustained light damage.
- Improper safety procedures and a failure to adequately assess operational risks were the primary contributing factors, driven by psychological factors including high motivation and diminished situational awareness.