What happened
On February 20, 2021, a PA-28-161 aircraft, registration PR-NEX, was performing a repositioning flight from FurnasPark Resort Aerodrome (SWVW) to Bragança Paulista (SBBP) for maintenance. The flight was operating under a Special Flight Authorization (AEV).
During the takeoff roll at SWVW, the engine experienced a drop in RPM followed by a total loss of power. The pilot attempted to execute a right-hand turn to return to the departure runway. During this maneuver at a low altitude, the right wingtip struck a wooden pergola, causing the aircraft to crash into the swimming pool of the FurnasPark Resort Hotel. The aircraft sustained substantial damage, including the separation of the right wing at the root. The pilot and two passengers sustained minor injuries.
The investigation
CENIPA investigators examined the wreckage and conducted engine functional tests. While standard components like spark plugs and compression were normal, the engine failed when the throttle was cycled from idle to maximum RPM. Upon inspection of the carburetor, investigators discovered a piece of fabric lodged within the venturi, which obstructed the airflow and disrupted the fuel mixture.
The investigation also reviewed security camera footage from the hotel, which showed a 64-second interval between takeoff and the initial impact. This duration suggested the aircraft's flight path was more complex than a direct return to the runway. Furthermore, investigators noted that the aircraft's airworthiness certificate had been expired since August 2019, and maintenance logbooks were not up to date.
Findings
- Carburetor obstruction: A fragment of anti-friction fabric, likely originating from a worn or poorly positioned component on the engine cowling, was sucked into the carburetor venturi, causing the engine failure.
- Maintenance deficiencies: The aircraft lacked updated maintenance records, and the presence of the fabric fragment indicated a failure in preventive maintenance procedures.
- Pilot judgment: The pilot failed to follow the manufacturer's prescribed procedures after experiencing engine roughness during a previous leg of the flight. Additionally, the decision to attempt a return to the runway via a turn, rather than landing straight ahead, was contrary to Pilot’s Operating Handbook (POH) recommendations.
- Regulatory non-compliance: The flight was carrying two passengers in violation of the restrictions set in the Special Flight Authorization (AEV).