What happened
On December 26, 2009, a Cessna T210L, registration N 2015 S, was conducting a ferry flight from Boa Vista (SBBV) to Manaus (SBEG), Brazil, as part of a larger journey from the United States to Bolivia. The flight had previously landed in Boa Vista, but due to the absence of customs officials at that location, the crew had not completed the required customs formalities or filed a flight plan for the leg to Manaus.
After landing and taxiing to the Cargo Terminal 2 apron at Eduardo Gomes Airport, the aircraft was met by Federal Police and Customs agents. As the pilot disembarked from the right-hand door, they paused to retrieve an object from the ground. While moving toward the waiting authorities, the pilot entered the propeller arc. The moving propeller struck the upper left side of the pilot's torso, causing the propeller to stop immediately. Although paramedics provided rapid medical assistance at the airport, the pilot succumbed to their injuries at Hospital João Lúcio later that morning. The other crew member was uninjured, and the aircraft sustained light damage.
The investigation
CENIPA's investigation focused on the sequence of events leading to the contact with the propeller. Investigators noted that the crew was qualified and held valid medical and pilot certificates, though they lacked specific experience with this aircraft model.
The investigation established that the crew was likely under pressure to address the authorities immediately due to the skipped customs procedures in Boa Vista. This apprehension may have led to the pilot failing to complete the full engine shutdown procedure before exiting the aircraft. Furthermore, the act of stopping to pick up an object on the ground caused a momentary lapse in situational awareness, preventing the pilot from noticing the danger of the propeller arc.
Findings
- Inattention during the movement toward the propeller arc.
- Improper engine shutdown procedures, leaving the propeller in motion.
- Lack of experience with the specific aircraft model.
- Distraction caused by retrieving an object from the ground.
Safety action
CENIPA issued a recommendation to the National Civil Aviation Agency (ANAC) to disseminate the lessons learned from this investigation to alert pilots and operators regarding the inherent risks of moving near the propeller arc.