What happened
On September 29, 2009, at approximately 21:03 UTC, a Piper PA-28-140, registration PT-DZR, was performing a night flight instruction maneuver at Pampulha Airport (SBBH) in Belo Horizonte, Brazil. The aircraft, operated by Starflight Academia de Aviação Civil Ltda, was arriving from Carlos Prates Airport for a scheduled refueling stop.
During the taxiing process, the flight instructor took control of the aircraft to navigate a tight parking space in the airport's remote area. As the aircraft attempted to maneuver into a designated slot, the ground marshaller moved from his position to inspect the clearance between the aircraft's wing and a previously parked plane. While returning to his position, the marshaller collided with the aircraft's spinning propeller. The impact resulted in serious injuries to the ground personnel and light damage to the aircraft's propeller. The two occupants of the aircraft remained uninjured.
The investigation
CENIPA's investigation focused on the infrastructure of the airport's remote parking area and the communication between the crew and ground staff. Investigators found that the parking markings in the remote area did not comply with international safety standards (ICAO Annex 14) or local regulations (RBAC 154). Specifically, the distance between parking markings was only 14 meters, which is insufficient for aircraft with a wingspan of up to 15 meters to maintain the required 3-meter safety margin from adjacent aircraft.
The investigation also highlighted environmental and operational factors. The incident occurred during sunset, which created significant glare and reduced visibility, making the rotating propeller difficult to see. Furthermore, investigators noted a lack of standardized procedures for ground marshallers at this location, observing that personnel often relied on personal judgment rather than technical safety margins. There was also a breakdown in communication; the marshaller believed he had signaled the pilot to shut down the engine, while the instructor claimed he did not receive this instruction.
Findings
- The remote parking area markings failed to provide the minimum required safety distance between aircraft.
- Inadequate airport infrastructure and non-compliant ground markings created a high-risk maneuvering environment.
- Poor visibility due to the sunset position obscured the movement of the propeller.
- A lack of standardized training and supervision allowed ground personnel to adopt non-standard, personalized safety distances.
- Communication failures occurred between the flight crew and the ground marshaller regarding engine shutdown.
- The flight instructor had limited experience with the specific wide-track characteristics of the Piper PA-28-140.