What happened
On June 27, 1999, at approximately 16:30, an EMB 710C, registration PT-NAB, was performing a taxi maneuver on an uncertified, clandestine runway in Piracanjuna, Goiás, when it collided with two pedestrians. The flight had departed from Luziânia, GO, with the intention of flying to Caldas Novas, GO; however, the crew decided to divert to the Piracanjuba strip to attend a local model aircraft event.
Upon arrival, the pilot observed that the runway was being used by large crowds and that children were entering the movement area through a side gate. Despite these hazards, the pilot proceeded to land. During the subsequent takeoff preparations, the pilot attempted to coordinate with another aircraft that had recently landed, but the other pilot refused a request to clear the runway.
As the pilot of PT-NAB began taxiing and executed a left turn to align with the runway, the right wingtip struck two individuals who were positioned on the runway. One person sustained minor injuries, while the other suffered severe injuries and passed away several days later. The aircraft sustained no damage.
The investigation
CENIPA's investigation focused on the decision-making process and the operational environment of the uncertified airfield. Investigators established that the pilot was aware the runway was not a certified or regulated facility and lacked any air traffic control or perimeter security to prevent unauthorized access.
The investigation examined the pilot's motivation, noting that the presence of a hobby-related event and the personal interests of the passengers influenced the decision to land at an unsafe location. Furthermore, the investigation reviewed the lack of flight planning, as no flight plan had been filed for the diverted destination, and noted that the pilot's attention was likely focused on the other aircraft on the runway, leading to the oversight of the pedestrians on the right side of the aircraft.
Findings
- High Motivation: The pilot's strong desire to attend the model aircraft event, reinforced by the passengers, led to a disregard for standard safety regulations.
- Uncertified Infrastructure: The use of a clandestine runway meant there was no controlled access to the movement area, allowing pedestrians to occupy the runway without oversight.
مت- Poor Risk Management: The pilot made the decision to land despite observing children and crowds near the runway, and later decided to taxi despite the lack of guaranteed clearance from the other aircraft.
- Inadequate Planning: The flight was conducted without a filed flight plan and involved a deviation from the original flight plan without proper regulatory compliance.
- Loss of Situational Awareness: The pilot's focus on coordinating with the other aircraft on the runway caused a failure to monitor the right side of the aircraft during the alignment turn.