What happened
On March 2, 2008, a Cirrus SR22, registration PR-IAO, crashed in the Barra da Tijuca neighborhood of Rio de Janeiro. The aircraft had arrived at Jacarepaguá Airport (SBJR) from Barra do Piraí for refueling. During the takeoff roll, approximately 10 seconds after leaving the ground, the air traffic controller observed smoke emanating from the aircraft and alerted the pilot, though no response was received.
During the initial climb, the engine lost power, causing the aircraft to enter a left-hand descending turn. The aircraft struck a masonry building, resulting in the total destruction of the airframe and four fatalities (one pilot and three passengers).
The investigation
CENIPA's investigation focused on the refueling process at the airport. The investigation established that the aircraft, which is designed to operate on AVGAS, had been refueled with 265 liters of JET A-1 kerosene.
The refueling operator stated they were servicing a different aircraft with a kerosene tanker when a person, believed to be the commander, requested service. The operator confirmed the fuel type verbally with this individual and proceeded with the fueling. The investigation found that the refueling company's procedures for verifying fuel type were not strictly followed, and there was no formal record of the specific fuel request. Furthermore, the operator admitted to being inexperienced with this specific aircraft model and did not challenge the verbal instruction provided by the individual present.
Findings
- Incorrect fuel type: The aircraft was fueled with JET A-1 kerosene instead of the required AVGAS.
- Human factors: The refueling operator failed to verify the aircraft's requirements and relied on a verbal request from an individual they assumed was the commander.
- Organizational failures: The refueling company lacked a structured procedure for handling discrepancies between requested and required fuel types, and the refueling person's presence during the process prevented the identification of the error.
- Regulatory gaps: There was a lack of formal regulation regarding the use of specialized nozzle attachments (often called "duckbill" connectors) that serve as a physical defense against incorrect fueling.