What happened
On July 18, 2003, a Cessna C-210N, registration PT-OUK, was performing a flight from Vera Cruz, São Paulo, to Campo Grande, Mato Grosso do Sul. The pilot had completed the first leg of the trip and was descending toward Campo Grande for the return leg of the mission. During the descent, the pilot noticed the engine was vibrating irregularly.
As the aircraft approached the traffic pattern for Campo Grande, the engine failed completely. The pilot attempted an emergency landing on the BR-2/62 highway. During the approach, the right wing of the aircraft struck the treetops. Upon touchdown on the paved highway, the left wing collided with two trucks traveling in the opposite direction, causing the wing to separate from the fuselage. Despite the severe damage to the aircraft, the pilot and the truck drivers were unharmed.
The investigation
CENIPA investigators examined the aircraft's maintenance records, the pilot's experience, and the fuel management for the mission. The investigation confirmed that the aircraft's maintenance was up to date and that the engine and airframe were in proper condition. Meteorological conditions at the time of the accident were favorable for VFR flight.
Investigators found that the aircraft's fuel tanks and fuel filter were empty at the time of the initial inspection. The investigation also revealed that the pilot had planned the flight to cover both legs of the trip—Campo Grande to Vera Cruz and back—without refueling in Vera Cruz. The pilot had calculated the fuel load to be exactly what was needed for the flight time, intentionally omitting the regulatory fuel reserve.
Findings
- Fuel exhaustion was the primary cause of the engine failure.
- The pilot failed to include the mandatory 30-minute fuel reserve required for VFR day operations under RBHA 91.151.
- Inadequate flight planning contributed to the accident, as the pilot did not account for variables such as headwinds, route deviations, or unexpected holding patterns.
- The pilot's role as both owner and operator meant there was a lack of external supervision to correct the flawed fuel planning.
- The pilot's judgment was compromised by the decision to fly with no margin for error, assuming no unforeseen circumstances would arise.