What happened
On January 25, 2000, an Aeroboero AB-115, registration PP-GCN, was parked in front of a hangar at the Aeroclube de Pelotas in Pelotas, RS, prepared for taxiing to a refueling station. The aircraft was occupied by a pilot and a passenger, who was a student at the flying club.
After the engine was started, the pilot realized that the wheel chocks had been left in place. The pilot placed the engine at idle speed and instructed the passenger to exit the aircraft to remove them. While attempting to remove the chocks from the main landing gear, the passenger's right arm collided with the rotating propeller, resulting in serious injuries to the passenger. The aircraft sustained no damage during the incident.
The investigation
CENIPA's investigation revealed several systemic failures within the flying club's operations. The pilot in command had very limited experience with the aircraft type and was operating with an expired medical certificate. Furthermore, the investigation found that the club's instructors had not completed the required Standardization Instructor Course for the Aeroboero AB-115, leading to inconsistent training and a lack of standardized procedures for normal and emergency operations.
Investigators also identified a lack of administrative oversight. The club did not maintain proper control over the validity of pilots' technical licenses or medical certificates. The organizational culture was described as being centered around a single individual, with a lack of active participation from the flight safety and instruction directorates, which fostered a state of complacency.
Findings
- Deficient Instruction: The lack of standardized instructor training led to inconsistent training for pilots, specifically regarding the correct execution of checklists.
- Poor Judgment: The pilot incorrectly assessed the risk of having a passenger perform ground tasks while the engine was running.
- Lack of Supervision: Inadequate administrative oversight allowed a pilot with an expired medical certificate to operate the aircraft and permitted instructors to teach without proper standardization.
- Operational Errors: The pilot failed to follow the aircraft's checklist, which requires chocks to be removed prior to engine start, and the passenger's actions were influenced by a lack of standardized safety procedures.