What happened
On April 26, 1997, a Cessna 175, registration PT-BHW, was performing non-profit scenic flights at Atibaia Aerodrome in São Paulo. Following a landing, the pilot was taxiing the aircraft toward the parking area when several individuals approached the plane. To ensure safety, the pilot halted the taxiing process, but left the engine running.
During this pause, the passengers on board disembarked, and two new individuals entered the rear seats, requesting an additional flight. As the pilot decided to shut down the engine due to the crowd gathering near the aircraft, a third person—a passenger from a previous flight—attempted to walk around the front of the aircraft to occupy the front passenger seat. During this movement, the individual collided with the propeller, which was still in motion, resulting in one fatality.
The investigation
CENIPA's investigation focused on the operational environment and the pilot's adherence to safety protocols. Investigators examined the airfield's infrastructure, noting that the perimeter fence was in poor condition with multiple openings, allowing pedestrians to freely cross the operational area for leisure or transit.
The investigation also reviewed the pilot's compliance with Brazilian civil aviation regulations (RBHA 91). It was established that the pilot had not provided a safety briefing to the passengers regarding the dangers of boarding or disembarking while the engine was running. Furthermore, the investigation looked into the lack of access control at the aerodrome, which allowed unauthorized persons to enter the taxiway and runway areas.
Findings
- Deficient Supervision: The local administration failed to control access to the operational area, and the perimeter fencing was inadequate to prevent unauthorized pedestrian movement.
- Deficient Judgment: The pilot did not immediately shut down the engine upon noticing people approaching the aircraft.
- Operational Non-compliance: The pilot failed to follow RBHA 91 regulations regarding passenger boarding/disembarking with engines running and did not brief passengers on safety procedures.
- Inadequate Infrastructure: The aerodrome lacked effective monitoring of aircraft operations and had significant gaps in its protective boundaries.
Safety action
CENIPA issued several safety recommendations, including:
- A directive to the Municipality of Atibaia to allocate staff for monitoring aircraft and pedestrian movement and to repair or replace the perimeter fencing.
- A requirement for SERAC 4 to conduct a flight safety inspection of the aerodrome.
- Instructions for safety investigators to orient pilots on the risks of engine operation during passenger movement and the importance of adhering to RBHA 91 protocols.