What happened
On April 4, 1996, a Cessna 210L, registration PT-JBC, was positioned at the head of a runway in Mirassol D’Oeste, Mato Grosso, preparing for a flight to Moraes de Almeida, Pará. The aircraft was carrying the pilot and one passenger.
While aligned for takeoff, the passenger informed the pilot of an urgent physiological need due to sudden intestinal distress. Before the pilot could instruct the aircraft to taxi back to the parking area, the passenger exited the aircraft via the right-side door without authorization. In the process of disembarking, the passenger walked into the path of the operating propeller, striking their left arm. Despite receiving medical assistance and being transported to a local hospital, the passenger succumbed to their injuries during transfer to a second medical facility.
The aircraft sustained minor damage during the event.
The investigation
CENIPA's investigation focused on the sequence of events leading to the propeller strike and the operational environment. The investigation established that the aircraft was operating from an unregulated, clandestine airfield consisting of a gravel surface.
Investigators examined the pilot's credentials and found that while the pilot held a valid Commercial Pilot License and single-engine rating, their medical certificate (CCF) had expired. Furthermore, the investigation noted that the pilot had failed to conduct a safety briefing with the passenger regarding boarding and disembarking procedures. The investigation also highlighted a breakdown in communication, as the pilot was unable to effectively alert the passenger to the danger before the passenger exited the aircraft.
Findings
- Human Factors: The passenger's urgent physiological distress led to impaired judgment and a lack of situational awareness, causing them to approach the moving propeller.
- Operational Deficiencies: The pilot failed to perform a safety briefing for the passenger regarding aircraft exit procedures. Additionally, the operation involved an unauthorized airfield and the use of an expired medical certificate.
- Communication Failure: The pilot did not successfully communicate the necessity of remaining in the aircraft or the plan to taxi back to the apron before the passenger disembarked.