What happened
On March 31, 2011, at the Aeródromo Nacional de Aviação (SWNV) in Goiânia, Brazil, a Cessna 210L, registration PT-IRJ, was undergoing a post-maintenance engine check. The pilot had intended to perform a local flight to verify equipment following a recent inspection. During the taxi to the engine check area, the pilot identified malfunctions in the fuel injection system and the headset connector (PTT).
Rather than shutting down the engine, the pilot decided to taxi to the engine test area to continue troubleshooting. Upon arriving at the test area, the pilot observed another aircraft nearby and decided to approach it to request a spare headset connector. The pilot exited the Cessna 210L while the engine was still running. As the pilot attempted to wave to the occupant of the other aircraft, their right arm came into contact with the propeller blades, resulting in serious injuries to the pilot. The aircraft sustained no damage.
The investigation
CENIPA's investigation examined the pilot's actions and the circumstances surrounding the engine run-up. Investigators found that the pilot had valid medical and flight certifications, and the aircraft's airworthiness documentation was up to date. The investigation also addressed a discrepancy regarding the presence of a passenger; while the pilot claimed someone else was on board, witnesses and investigators could not verify this, leading to the conclusion that the pilot was alone.
Investigators analyzed the pilot's decision-making process, noting that the pilot had bypassed standard safety procedures and failed to follow the Brazilian Aeronautical Code, which prohibits leaving an aircraft with the engine running without a crew member on board. The investigation also ruled out the possibility that the aircraft had moved unexpectedly, as the parking brake was applied and the brakes were found to be functional.
Findings
- The pilot abandoned the aircraft with the engine running to approach another aircraft.
- The pilot's focus was on communicating with the other pilot rather than assessing the immediate risks of the propeller's arc of motion.
- The pilot's decision to exit the aircraft with the engine running was a primary contributing factor.
- Contributing factors included diminished situational awareness, poor decision-making, and a lack of attention to the hazards of walking near active propellers.