What happened
On November 29, 2019, at approximately 21:55 UTC, an Embraer EMB-201A agricultural aircraft, registration PT-UGJ, was performing a landing at the Guararapes Aerodrome (SDGR) in São Paulo, Brazil. The aircraft had been conducting agricultural spraying operations at a nearby farm and was returning to the aerodrome for its final landing.
As the pilot was on final approach and nearing the touchdown point, they observed individuals walking along the side of the runway. This observation caused a momentary distraction. Upon refocusing on the landing, the pilot discovered a pedestrian and a child with a bicycle directly in the aircraft's path. The pilot was unable to avoid the collision, and the aircraft's chemical application boom struck one of the pedestrians. The impact resulted in serious injuries to one pedestrian, while the second pedestrian and the pilot remained uninjured. The aircraft sustained substantial damage.
The investigation
CENIPA's investigation focused on the operational environment and the safety of the aerodrome's perimeter. The investigation established that the pilot was fully qualified, holding valid commercial and agricultural licenses, and had sufficient flight experience in the region. The aircraft was airworthy and within weight and balance limits, although records for the engine, propeller, and airframe were not up to date.
Investigators identified that a pedestrian crossing was established that intersected the active runway. While the aerodrome featured perimeter fencing and warning signs prohibiting unauthorized entry, the fencing was found to be of low security and easily bypassed by both people and animals. Furthermore, the investigation revealed that the aerodrome, managed by the Municipality of Guararapes, had been operating without recent regulatory oversight. ANAC had only initiated a remote inspection process in June 2019, and the accident occurred while the regulatory status of the aerodrome was still being evaluated.
Findings
- The presence of a pedestrian crossing cutting through the runway.
- Inadequate airport infrastructure, specifically fencing that was easily bypassed by pedestrians and animals.
- A momentary loss of attention by the pilot due to observing movement on the runway periphery.
- The lack of effective enforcement of the aerodrome's perimeter boundaries.