What happened
On January 6, 2000, an EMB 201 aircraft, registration PT-GHV, was engaged in agricultural spraying operations at Fazenda Beltrão in Campos de Júlio, Mato Grosso. Following the first flight of the day, the aircraft landed to replenish its pesticide tanks.
During this refueling process, the pilot exited the cockpit while the engine remained running. Witnesses reported that the pilot exited the nacelle via the right side, climbing over the leading edge of the right wing using the landing gear as an improvised step. While walking toward the front of the aircraft, the pilot was struck by the moving propeller. The pilot sustained fatal injuries and died at the scene. The aircraft sustained no damage.
The investigation
CENIPA's investigation focused on the sequence of events leading to the contact with the propeller. The investigation examined the pilot's experience, noting that while qualified, he had only 32 hours of experience in this specific aircraft type and was relatively new to agricultural aviation, having started the role only one month prior.
The investigation explored several hypotheses regarding why the pilot exited the aircraft without shutting down the engine. These included the possibility of the pilot feeling unwell due to pesticide inhalation (despite wearing a gas mask), an urgent physiological need, or a voluntary decision to exit while the engine was running to avoid the delay of a restart. Investigators also noted that the pilot was wearing a flight helmet, which likely restricted his peripheral vision and hearing, contributing to his lack of situational awareness regarding the propeller's position.
Findings
- Improper exit procedure: The pilot failed to shut down the engine before exiting the aircraft, violating basic safety regulations and the Brazilian Aeronautical Code.
- Deficient judgment: The pilot's decision to exit the aircraft and navigate toward the front of the wing while the engine was active demonstrated a critical error in judgment.
- Lack of supervision: The operator had not implemented a formal evaluation or continuous supervision process for the pilot, who was operating with limited experience in agricultural spraying.
- Improper use of aircraft features: The pilot utilized the leading edge of the wing and the landing gear as a makeshift step, a practice sometimes used by agricultural pilots to avoid spraying equipment, but which is unsafe when the engine is running.
- Inadequate situational awareness: The use of a flight helmet likely reduced the pilot's ability to perceive the proximity of the moving propeller.