What happened
On December 18, 2013, an EMB-202 aircraft, registration PT-UHX, was positioned at a landing strip in Granja Ibicuí, Itaqui, RS, for agricultural application operations. During the process of replenishing the aircraft with fertilizer (urea), the engine was left running at idle speed.
After completing the loading, a ground crew member, who had been positioned on the right wing, attempted to descend from the aircraft by climbing down the leading edge of the wing. During this movement, the individual struck their face against the rotating propeller. The impact resulted in fatal injuries due to traumatic brain injury. The pilot remained uninjured, and the aircraft sustained no damage.
The investigation
CENIPA's investigation focused on the operational environment and the organizational structure of the operator. The investigation established that the company lacked formal written operational procedures or standardized communication protocols between the pilot and ground personnel. Training for ground crew members was informal, often conducted by pilots on-site rather than through a structured program.
Investigators also noted that the practice of keeping the engine running during the loading of agricultural inputs was a common culture among local operators. While the aircraft's airworthiness certificate was valid, the investigation found that the maintenance logs for the airframe, engine, and propeller had not been updated since June 2013.
Findings
- Lack of formal procedures: The absence of established operational routines and written instructions contributed to improvised and unsafe behaviors.
- Communication failure: The lack of standardized hand signals or communication channels between the pilot and the ground crew led to a failure in coordinating the descent from the wing.
- Inadequate training: The company lacked a formal training and competency program, relying on informal instruction that failed to reinforce safe behaviors.
- Organizational culture: The practice of maintaining engine power during fertilizer loading created a high-risk environment.
- Unsafe personnel behavior: The ground crew member's decision to descend via the leading edge of the wing, combined with a previously noted pattern of impulsive behavior, was a direct factor in the collision.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to:
- Ensure the operator establishes a minimum training curriculum for all personnel interacting with aircraft, covering all procedures from loading to flight.
- Verify the operator's compliance with its Safety Management System (SMS).
- Review existing regulations for agricultural aviation to evaluate the need for specific procedures regarding the loading of liquid and solid agricultural products.