What happened
On September 23, 2003, at approximately 18:00, an EMB-201A Ipanema, registration PT-GSN, landed at an unregistered dirt airstrip on the Fazenda Dona Carolina in Lagoa da Confusão, Tocantins. The aircraft, operated by Aeronorte Aviação Agrícola Ltda, was conducting a reconnaissance flight to identify agricultural areas for future spraying services.
Following the landing, a person waiting at the farm assisted the pilot in taxiing the aircraft approximately 300 meters to a parking spot along a nearby road. According to a witness, this individual was seated on the aircraft's left wing during the taxiing process. As the aircraft came to a stop, the individual attempted to dismount by bracing themselves against the left landing gear. During this movement, the person lost their balance and struck their head against the propeller, which was still rotating. The pilot felt a sudden jolt and vibration in the engine and immediately shut down the motor. Although the individual was transported to a hospital, they succumbed to their injuries.
The investigation
CENIPA's investigation examined the pilot's experience, the aircraft's maintenance history, and the operational circumstances of the flight. The pilot was highly experienced, with approximately 3,000 hours in agricultural aviation. The aircraft's maintenance records were found to be up to date, and the engine and airframe inspections were current.
Investigators noted significant contradictions between the pilot's testimony and that of a witness. The pilot claimed the individual approached the aircraft from the side and that he did not see them until the impact occurred. However, a witness stated they observed the individual sitting on the wing for the entire 300-meter taxi. The investigation also highlighted that the landing took place during twilight under cloudy conditions at an unauthorized, unregistered airstrip.
Findings
- Improvisation and lack of safety oversight: The pilot allowed an unqualified person to be transported on the wing of the aircraft and failed to provide safety instructions regarding the hazards of the moving propeller.
- Deficient planning: The mission lacked adequate preparation, specifically regarding the failure to request qualified ground support personnel and the decision to land at an unauthorized location.
- Operational indiscipline: The flight was conducted beyond the planned daytime hours, during twilight with reduced visibility.
- Human factors: The incident involved a lack of adherence to flight safety standards and the use of improvised ground procedures.