What happened
On Thursday, November 20, 2003, at 15:40, a trainee pilot was performing engine checks on an Air Création Safari GT ultralight, identified as 26-GQ, at the Romans aerodrome. The aircraft, powered by a Rotax 462 engine, was being moved out of a hangar for the purpose of verifying engine functionality.
During the engine start sequence, the engine failed to ignite on the first attempt. Once the pilot successfully started the engine, the aircraft began to move forward unexpectedly. During this movement, the rotating propeller struck the pilot, resulting in one fatality. The aircraft continued to gain speed, briefly lifted off the ground for several meters, and ultimately collided with a hangar wall, causing minor damage to the airframe.
The investigation
The investigation focused on the engine start procedures and the physical positioning of the pilot during the event. Because of the specific ergonomics of the Air Création Safari GT, the pilot was required to stand to the right of the aircraft to access the controls. To prevent the aircraft from rolling, the pilot attempted to secure the tricycle gear by placing his left leg against the rear right wheel, as the braking mechanism is operated via the left pedal and was inaccessible during the start sequence.
Investigators examined the engine controls and found the choke in the closed position and the throttle set to approximately 50% of maximum power. The manufacturer's manual specifies that the throttle should be set to idle and that the choke should be closed after a few seconds of operation. The investigation also noted that the aircraft was not equipped with a parking brake.
Findings
- The pilot was using an improvised starting procedure that deviated from established safety protocols.
- The pilot's attempt to stabilize the aircraft using his leg left him vulnerable to the aircraft's unexpected forward motion.
- The engine was running at a high power setting (50% throttle) during the incident, which contributed to the sudden acceleration of the aircraft after the engine ignited.