What happened
On August 19, 2000, a Cessna 210H, registration PT-DJB, was conducting a series of sightseeing flights at an uncertified airstrip located at Fazenda Quicé, in Guaraciaba do Norte, Brazil. The operation was intended to provide short 15-minute flights for a group of 15 local motorcycle taxi drivers.
Following the first flight of the series, the pilot taxied the aircraft toward a designated area for passenger exchange. Although the pilot noticed a large crowd of onlookers gathering near the runway, they proceeded to stop the aircraft at the previously agreed-upon location while the engine was still running. During this process, a woman approached the left side of the aircraft and attempted to walk around the front of the plane. As she moved toward the nose, she struck the moving propeller, sustaining fatal injuries at the scene.
The investigation
CENIPA's investigation focused on the operational environment and the pilot's decision-making. The investigation established that the aircraft was operating from an uncertified landing strip that lacked proper perimeter control; the single entrance gate had been left open, allowing curious bystanders to enter the operational area.
Investigators examined the pilot's briefing process, noting that while the passengers were instructed not to approach the aircraft while the propeller was spinning, the airfield's security personnel (the field guard) had not been briefed on controlling access or managing the crowd. The investigation also considered environmental factors, such as the sun's position at approximately 25 degrees above the horizon, which, combined with the victim's sunglasses, likely obscured the visibility of the rotating propeller.
Findings
- The pilot demonstrated deficient judgment by deciding to taxi and park the aircraft in close proximity to a gathering crowd.
- The operation was conducted at an uncertified airstrip without adequate crowd control or perimeter security.
- There was a lack of proper planning regarding the briefing of ground support personnel to manage the influx of unauthorized persons.
- The pilot's decision to operate from an uncertified strip was a violation of flight discipline.
- The victim's sudden movement toward the aircraft, potentially influenced by the sun's glare and the propeller's slipstream, contributed to the collision.