What happened
On February 18, 2022, an EMB-201A agricultural aircraft, registration PT-GZJ, departed from the Dracena Aerodrome (SDDR) in São Paulo, Brazil. The flight was a repositioning mission intended to transport agricultural chemicals for application at a nearby landing site.
During the initial climb phase following takeoff, the aircraft experienced a sudden loss of engine power. The pilot attempted to execute a turn to return to the runway, but the aircraft struck the airfield's perimeter fence. The impact triggered a fire that consumed the aircraft's structure. The pilot sustained minor injuries, but the aircraft was destroyed.
The investigation
CENIPA investigators examined the wreckage and identified that cylinder number 5 was missing from the Lycoming IO-540 engine. Analysis of the engine components revealed significant damage to the piston, connecting rod, and engine block, as well as high concentrations of metal shavings in the oil filters.
Technical examination of the cylinder's studs (through bolts) revealed that they had fractured due to fatigue, evidenced by characteristic "beach marks." Investigators also noted that the engine and the servo unit lacked identification plates. While maintenance records showed the aircraft had undergone a general overhaul in 2012, the specific service order for that overhaul was unavailable for review because the maintenance organization had exceeded the five-year record-retention period. Consequently, investigators could not confirm if the manufacturer's service bulletin—which mandates the replacement of these stressed bolts during overhaul—had been followed.
Findings
- The engine failure was caused by the loss of cylinder number 5 due to the fatigue failure of its through bolts.
- The pilot was properly qualified and the aircraft was within weight and balance limits.
- The aircraft was operating under Visual Flight Rules (VFR) in favorable meteorological conditions.
- The loss of the cylinder caused immediate power loss and subsequent internal engine damage.
- Maintenance of the aircraft remains an undetermined contributing factor due to the lack of available historical maintenance documentation.