What happened
On January 4, 2015, a Super Petrel LS, registration PU-PEK, departed from the Toledo Municipal Airport in Paraná, Brazil, bound for the Cascavel Ultralight Aeroclub. During the initial climb, approximately three nautical miles from the departure point, the aircraft experienced an engine failure. Following the loss of power, the aircraft pitched up abruptly and entered a spin, eventually impacting the ground in a rural area near Toledo. The pilot sustained fatal injuries at the scene, and the aircraft suffered substantial damage.
The investigation
CENIPA investigators examined the engine, a Rotax 912 ULS 2, and discovered that a fragment had detached from the internal layer of a hose. This specific component should have been replaced in accordance with Service Bulletin ASB-912-061UL R1. While the aircraft's records indicated that the bulletin had been complied with during manufacturing, the investigation revealed a deficiency in the quality control process regarding the application of service bulletins. Furthermore, the investigation noted that the wording of the Service Bulletin was ambiguous, which could lead to differing interpretations regarding its applicability to certain engine serial numbers.
Regarding the flight dynamics, investigators found that the pilot's training was insufficient for the circumstances. The pilot had limited experience with the specific aircraft type and had not received practical training for identifying and recovering from a spin. During the emergency, the pilot utilized improper control inputs while attempting to recover from the stall and subsequent spin.
Findings
- Engine failure caused by a fragment detaching from an internal layer of a hose that required replacement per a service bulletin.
- Inadequate control inputs by the pilot during the attempt to recover from the stall and spin.
- Deficiencies in manufacturing quality control regarding the verification and application of engine service bulletins.
- Insufficient pilot training, specifically lacking practical instruction in stall recognition and spin recovery.
- Ambiguity in the Service Bulletin (ASB-912-061UL R1) regarding its applicability to specific engine serial numbers.
- Regulatory gaps that allowed for the operation of experimental aircraft and the issuance of licenses without mandatory spin recovery training.