What happened
On February 13, 2021, a Beechcraft A36, registration PT-KQE, was performing a private flight from Novo Progresso to Itaituba in the state of Pará, Brazil. Approximately 20 minutes after takeoff, the aircraft experienced a sudden engine failure. The pilot was forced to perform an emergency landing in a field at Fazenda Beira Rio, near Novo Progresso. During the landing sequence, the aircraft collided with trees before striking the ground, resulting in substantial structural damage to the airframe. The pilot sustained minor injuries, while the three passengers on board were uninjured.
The investigation
CENIPA investigators determined that the engine failure was caused by the fragmentation of the engine's crankshaft. The investigation revealed significant discrepancies in the aircraft's technical records. While some maintenance maps suggested the engine had approximately 3,650 total hours, other records indicated a much lower figure of 2,530 hours at a previous inspection date. Furthermore, the aircraft's logbooks were found to be out of date, with the last entries dating back to 2008, and only 100 flight hours had been recorded in the preceding nine years.
Investigators also found that the engine had not undergone a major overhaul since December 1995. Although regulations at the time allowed operators to postpone calendar-based inspections if an operational assessment was performed, there were no objective criteria to guide such decisions. The investigation concluded that the lack of accurate flight hour tracking and the failure to adhere to manufacturer-specified maintenance intervals likely led to the engine operating beyond its safe limits.
Findings
- The engine crankshaft suffered a structural failure (fragmentation).
- Inaccurate maintenance tracking and inconsistent engine hour records led to the engine operating outside of its prescribed maintenance program.
- The aircraft's logbooks were not up to date, hindering effective airworthiness oversight.
- The pilot operated the aircraft in weather conditions that were not consistent with visual flight rules (VFR), despite not being qualified for instrument flight.
- The maintenance organization's records contained technical inaccuracies regarding component control.