ASN Wikibase Occurrence # 274203
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| Date: | Saturday 15 January 2022 |
| Time: | |
| Type: |  Piper PA-25-260 Pawnee C |
| Owner/operator: | Soldeira Aviação Agrícola Ltda. |
| Registration: | PR-SOD |
| MSN: | 25-5154 |
| Year of manufacture: | 1969 |
| Fatalities: | Fatalities: 0 / Occupants: 1 |
| Other fatalities: | 1 |
| Aircraft damage: | Minor |
| Category: | Accident |
| Location: | São Domingos Sugar Mill, Uchôa, SP -
 Brazil
|
| Phase: | Landing |
| Nature: | Agricultural |
| Departure airport: | São Domingos Sugar Mill, Uchôa, SP |
| São Domingos Sugar Mill, Uchôa, SP | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
At around 09:30 UTC, the aircraft took off from the ag airstrip at São Domingos Sugar Mill, municipality of Uchôa, State of São Paulo, on a local flight for the application of agricultural products.
During the landing run, the aircraft collided with a vehicle and veered to the right, hitting a truck and the runway assistant standing next to the vehicle.
The aircraft sustained minor damage. The crewmember got out unhurt, whereas the runway assistant sustained fatal injuries.
Contributing factors.
- Attention – undetermined.
The occurrence of rain hours before the operation, on a runway also used by other vehicles, contributed to the fact that it was not possible to control the aircraft in the space available.
Such conditions may have favored the occurrence of losses in the operator's attention and performance, since it was necessary to manage several distinct points of attention in a short time.
- Organizational culture – a contributor.
The practice of keeping ground-vehicles parked within the limits of the landing area, in addition to the procedure of backtracking the aircraft close to the said vehicles, denoted the intention of speeding up operations, despite the risks associated with such procedures. In addition, the lack of connection between the tailwheel and the steering rudder to make this operation viable, despite the prescriptions contained in the aircraft manuals, allowed to reinforce the existence of misconceptions in collective perceptions with respect to safety.
- Handling of aircraft flight controls – undetermined.
The marks left by the aircraft's tires on the surface of the landing area allowed one to raise the hypothesis that the aircraft had floated after the first touchdown, something that might indicate that the speed maintained on the final for landing was higher than ideal.
This fact may have contributed to making it hard to obtain control after landing, leading the aircraft to collide with the parked vehicle.
- Piloting judgment – a contributor.
There was inadequate assessment of the parameters involved in the operation in progress, particularly with regard to the slippery condition of the landing area, the partial use of the space available for landing, and the presence of vehicles in that location, contributing to the occurrence.
- Perception – a contributor.
The landing took place in a scenario that involved, in addition to accumulation of water and mud due to rain, obstacles on the airstrip resulting from its deterioration by the traffic of vehicles, and reduction in its length.
Furthermore, there was a vehicle parked at the end of the landing area, with which the aircraft collided, showing that the space reserved for the operation was compromised.
Landing under such conditions denoted a reduction in the pilot's situational awareness, as the risks were not adequately assessed.
- Managerial oversight – a contributor.
Even though a specific SRM was not presented for the location of operations, the characteristics of the landing area and the positioning of vehicles within its limits posed high risk to the safety of operations, for which there were neither control measures nor possible mitigations.
Also due to the lack of control relative to compliance with the equipment's operating manual, in view of the missing connection between the tailwheel and the steering rudder, as well as practices aimed at optimizing operations, the investigation demonstrated the existence of inadequacies in the oversight processes put in place by the management staff.
Accident investigation:
 |
|
Sources:
https://www.diariodaregiao.com.br/cidades/jovem-morre-apos-ser-atingido-por-helice-de-avi-o-agricola-em-uchoa-1.861339
https://www.gazetainterior.com.br/view/55639/Jovem-de-24-anos-morre-apos-ser-atingido-por-aviao-em-Uchoa-SP
https://www.gazetaderiopreto.com.br/cidades/noticia/2022/01/rapaz-morre-apos-ser-atingido-por-helice-de-aviao-pilotado-pelo-pai.html
https://paisefilhos.uol.com.br/familia/jovem-morre-ao-ser-atingido-por-aviao-agricola-pilotado-pelo-pai/
https://sistemas.anac.gov.br/aeronaves/cons_rab_resposta.asp?textMarca=PRSOD
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 16-Jan-2022 22:03 | gerard57 | Added |
| 17-Jan-2022 06:25 | RobertMB | Updated [Aircraft type, Registration, Cn, Operator, Location, Nature, Source, Damage, Narrative] |
| 17-Jan-2022 06:26 | RobertMB | Updated [Registration] |
| 17-Jan-2022 07:40 | cleberjc | Updated [Location, Departure airport, Destination airport, Source, Embed code, Damage, Narrative] |
| 17-Jan-2022 15:30 | RobertMB | Updated [Location, Departure airport, Destination airport, Source, Narrative] |
| 15-Mar-2024 09:04 | ASN | Updated [Operator, Location, Departure airport, Destination airport, Embed code, Narrative, Accident report] |
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