What happened
On February 9, 2007, a Cessna 310K, registration PT-LFV, operated by Ceará Táxi Aéreo Ltda, was performing a bank mail transport mission. The flight route included legs between Fortaleza, Iguatu, and Juazeiro do Norte. After taking off from runway 16 at the Iguatu Aerodrome (SNIG) bound for Fortaleza, the pilot experienced a failure of the right engine, which caused the aircraft to yaw significantly to the right.
The pilot attempted to maneuver the aircraft to return to the runway but was unable to maintain control. This resulted in a forced landing approximately 250 meters from the takeoff point, at a 4/5 angle relative to the runway axis. The impact caused the aircraft to be totally destroyed, with the exception of the tail section (horizontal and vertical stabilizers, elevators, and rudder). The pilot sustained minor injuries.
The investigation
CENIPA investigators examined the wreckage and the engine components. An inspection of the right engine revealed no mechanical defects or material failures that would account for the power loss. However, analysis of the wreckage and fuel logs indicated that the fuel selectors were not in the positions required by the aircraft's flight manual. Specifically, the right fuel selector was set to the auxiliary tank, and the left selector was in the crossfeed position.
The investigation also looked into the operational environment of bank mail transport, noting that the pressure to meet strict banking schedules and the need to minimize time on the ground due to security risks (theft prevention) often lead to rushed procedures. While the pilot initially denied using the auxiliary tanks, subsequent evidence and a revised statement confirmed that the fuel selectors were incorrectly positioned during the critical takeoff phase.
Findings
- The pilot failed to properly utilize the pre-takeoff checklist, leading to the incorrect positioning of the fuel selectors.
- The fuel selectors were set to the auxiliary tanks instead of the main tanks, which is contrary to the flight manual's recommendations for takeoff and landing phases.
- Operational pressures related to banking schedules and security concerns contributed to a reduction in situational awareness and the omission of checklist items.
- Deficiencies in the operator's training and instruction processes regarding standardized procedures and manual compliance were identified.
- The pilot was unable to effectively manage the aircraft's controls following the engine failure to execute a safe single-engine approach.