What happened
On February 10, 2008, at approximately 12:00 UTC, a Cessna A188B, registration PR-FFG, was engaged in agricultural spraying operations at Fazenda Santo Antônio in Paragominas, Brazil. After a short flight from a nearby landing strip, the aircraft landed to replenish its hopper with herbicide.
Following the refueling, the pilot started the engine and began performing internal cockpit checks, including verifying engine parameters and GPS settings. During this time, a farm employee noticed that the aircraft's wheel chocks had not been removed. The employee approached the left side of the aircraft to remove the chock from the left wheel. While still in a crouched position, the worker moved backward toward the propeller and was struck by the rotating blades. The impact resulted in one fatality and caused light damage to the aircraft's propeller.
The investigation
CENIPA's investigation established that the pilot had taken on responsibilities outside of his standard operating procedures due to external pressure. A representative of the farm administration had requested that the pilot accelerate the procedures to finish the workday early. Consequently, the pilot decided to perform the herbicide refilling himself rather than waiting for the company's ground assistant, who had temporarily left the site to procure additional fuel.
Because the pilot was rushing to meet the requested timeline, he bypassed several critical safety steps required by company policy. Specifically, the pilot failed to conduct an external walk-around inspection and did not perform a safety briefing for the farm personnel involved in the operation. Furthermore, the investigation found that the pilot's attention was focused entirely on the cockpit instruments at the moment of the accident, leaving him unaware of the worker's approach.
Findings
- Pressure from third parties: The farm representative's request to expedite the work created a sense of urgency that led to procedural deviations.
- Failure to perform external inspection: The pilot did not check the aircraft's exterior, which would have identified the presence of the wheel chocks.
- Lack of safety briefing: No safety instructions were provided to the farm staff regarding the hazards of proximity to active propellers.
- Inadequate situational awareness: The pilot was preoccupied with internal cabin checks and did not notice the worker approaching the aircraft.
- Unprepared ground personnel: The farm employee lacked experience in agricultural aviation safety and was unaware of the dangers of approaching a running engine.