What happened
On January 2, 2015, a Cessna 210L, registration PR-RCZ, was performing a private flight from Naviraí to Campo Grande, Brazil. The aircraft was carrying a pilot and two passengers when, approximately 20 minutes into the flight at an altitude of 4,500 feet, the pilot heard a loud noise from the engine accompanied by an involuntary longitudinal movement of the propeller control lever. The pilot noted a drop in RPM, though specific engine parameters such as cylinder head temperature and oil pressure were not monitored during the event.
To avoid a collision with an oncoming truck on the MS-141 highway, the pilot executed an emergency landing on the shoulder of the road. The aircraft traveled approximately 150 meters across irregular, sloping terrain before coming to a stop. The impact resulted in substantial damage to the aircraft. The pilot sustained minor injuries, while the two passengers remained uninjured.
The investigation
CENIPA investigators examined the Continental 10-520-L engine and found no significant mechanical failures during ground testing; the engine operated normally during a 25-minute test run. However, upon disassembling the propeller, investigators discovered that the pin and link for blade number one were broken, and the threads on the blade base were damaged due to overload. It was determined that these damages likely occurred during the forced landing when the propeller blades struck obstacles on the ground.
The investigation also revealed that the aircraft's maintenance logs for the propeller were not up to date, specifically regarding a recent 50-hour inspection. Furthermore, the investigation noted that the pilot did not utilize the emergency checklist during the incident because the document was written in English, a language in which the pilot lacked proficiency.
Findings
- Language barriers: The pilot's inability to read the English-language checklist prevented the use of essential emergency resources.
- Inadequate monitoring: The pilot failed to monitor engine parameters (temperature, pressure, and oil) during the emergency.
- Pilot judgment: The decision-making process was limited by the lack of adherence to established emergency procedures.
- Maintenance records: Discrepancies were found in the aircraft's maintenance documentation regarding recent inspections.