What happened
On February 19, 2020, at approximately 18:30 UTC, a Piper PA-28-180 (registration PT-AOP) departed from the Guarapari Aerodrome (SNGA) in Espírito Santo, Brazil, bound for Vitória. The aircraft was carrying a pilot and one passenger on a private flight.
Witnesses at the airfield observed that the engine began to fail shortly after the aircraft passed the intersection of the runway and the apron. The engine exhibited erratic behavior, alternating between continuous power and sudden drops in performance. Following the loss of power, the pilot initiated a right-hand turn, executing more than 180 degrees of flight path in a descending attitude. The aircraft was unable to maintain a stable climb and eventually collided with buildings located approximately 145 meters from the apron. The impact resulted in the destruction of the aircraft and two fatalities.
The investigation
CENIPA investigators examined the aircraft's maintenance history and the physical wreckage. Although the engine itself was found to be mechanically operational at the time of the collision, laboratory analysis of fuel samples revealed the presence of water and a fluorinated polymer. Investigators also discovered two drops of water and debris within the carburetor bowl.
Evidence suggested that the aircraft's fuel tank filler caps had significantly worn seals. Because the aircraft had been parked outdoors and exposed to heavy rainfall in the days preceding the accident, water likely entered the tanks. Furthermore, investigators noted that the crew may have bypassed critical pre-flight inspection steps, such as draining the fuel sumps, which would have otherwise identified the contamination before takeoff.
Findings
- Fuel contamination caused by water ingress through worn fuel cap seals was the primary driver of the engine power loss.
- The pilot's decision-making regarding the emergency maneuver—executing a wide turn over a densely populated area rather than following the flight manual's recommendation to land straight ahead or make a shallow turn—contributed to the accident.
- Inadequate maintenance of the fuel tank seals allowed environmental moisture to compromise fuel quality.
- A lack of adherence to pre-flight procedures, specifically the failure to drain fuel sumps, prevented the detection of contaminated fuel.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to:
- Alert pilots and operators to the necessity of strictly following checklists, particularly regarding fuel quality assessments.
- Remind maintainers and operators of the importance of full compliance with maintenance procedures to ensure flight safety.