What happened
On September 20, 1998, an EMB-110 Bandeirante, registration PT-WAW, departed Manaus, Brazil, for Novo Aripuanã. During the flight, the flight crew altered the route at the request of a passenger—a local political candidate—to land at an uncertified airstrip in Canutama, Amazonas.
Upon arrival at the uncertified field, the aircraft taxied to a parking area where a large crowd had gathered to meet the passenger. To prevent the aircraft's tail from hitting the ground due to a center-of-gravity shift when passengers stood up, the commander implemented a routine procedure: he shut down the left engine but kept the right engine running to maintain forward momentum and air conditioning. While the co-pilot exited the cockpit to install a tail strut, a bystander, who appeared to be intoxicated and was carrying a sign, ran toward the right side of the aircraft and came into direct contact with the rotating propeller. The individual sustained fatal injuries and passed away before reaching a hospital.
The investigation
CENIPA's investigation focused on the operational decisions made by the crew and the status of the airfield. The investigation established that the crew was experienced and that the aircraft was in airworthy condition. However, investigators found that the crew's attention was focused on the technical procedure of securing the aircraft's tail, which led to a significant reduction in situational awareness regarding the surrounding crowd. The investigation also noted that the use of uncertified airstrips had become a routine practice for this operator to maintain the privacy of political passengers.
Findings
- The primary cause of the accident was the crew's failure to shut down both engines immediately upon parking in a crowded area.
- The crew's situational awareness was compromised by a focus on routine technical procedures.
- The landing took place at an uncertified airstrip that lacked proper perimeter security to prevent unauthorized access to the apron.
- The bystander's movement into the propeller arc was exacerbated by their visible state of intoxication.
- The operator lacked adequate administrative supervision to prevent the frequent use of uncertified landing sites.
- The flight crew intentionally operated at an uncertified airfield, contrary to existing regulations.