What happened
On September 2, 2007, a Cessna C-182C, registration PT-BJA, was performing an unauthorized aeromedical transport flight from Santana do Araguaia, PA, to Sítio Flyer, TO. The aircraft was carrying the pilot, two patients in critical condition, a nurse, and an attendant.
During the final approach to runway 13 at Sítable Flyer, the engine stopped, causing the aircraft to strike trees approximately 120 meters from the runway threshold. The impact caused the aircraft to strike the ground at a 90-degree angle. The collision resulted in one fatality among the passengers and three serious injuries to the remaining occupants, including the pilot. The aircraft sustained substantial damage and was considered a total loss.
The investigation
CENIPA investigators established that the primary cause of the engine failure was fuel exhaustion. Although the pilot provided conflicting accounts regarding refueling, investigators found only nine liters of fuel remaining in the tanks, which was significantly below the 30-liter unuseable fuel limit for this model. No evidence of fuel leaks was found during the inspection of the fuel lines or the crash site.
The investigation also revealed several critical safety violations regarding the aircraft's configuration and airworthiness. The aircraft's airworthiness certificate was suspended, and several mandatory inspections were overdue. To accommodate the patients, the pilot had removed the passenger seats, leaving the passengers with no seats or restraints. The patients were lying on the floor, and the nurse and an attendant were positioned toward the rear of the aircraft without seatbelts. The pilot was also not wearing a seatbelt at the time of the impact.
Findings
- Fuel exhaustion was the direct cause of the engine failure during the approach.
- The pilot failed to plan the flight with an adequate fuel margin, violating VFR regulations.
- The aircraft was being operated with expired maintenance inspections and a suspended airworthiness certificate.
- The flight was an improvised aeromedical operation using an aircraft not certified or equipped for such purposes.
- The removal of seats and lack of passenger restraints significantly increased the risk of injury during the impact.