What happened
On November 23, 2008, a Beech Aircraft 2/00, registration PT-OSR, was performing a flight from Teresina, PI, to Recife, PE, carrying eight passengers and two crew members. During the final approach to runway 18 at Recife, the aircraft experienced a simultaneous failure of both engines. The pilot was forced to perform an emergency landing in a residential neighborhood in the San Martin district. During the descent and impact, the aircraft collided with several houses. The accident resulted in two fatalities (the pilot and one passenger) and one serious injury among the passengers. The remaining six passengers sustained minor injuries. The aircraft was destroyed and considered a total loss.
The investigation
CENIPA's investigation established that the aircraft had been refueled in Recife prior to the first leg of the flight but was not replenished after landing in Teres andina. The investigation focused on the fuel management and the crew's qualifications. It was discovered that the pilot had recruited an unqualified co-pilot for the flight due to the unavailability of his regular crew member. Furthermore, the flight plan contained inaccurate information, as the pilot used the license number of a different pilot who was not on board. The investigation also examined the operational decision-making regarding the decision to proceed with the return leg without adequate fuel reserves.
Findings
- The primary cause of the accident was fuel exhaustion (dry tank).
- The pilot failed to refuel the aircraft in Teresina, leaving insufficient reserves for the return flight to Recife.
- The pilot operated the aircraft with an unqualified co-pilot who lacked the necessary multi-engine rating.
- There was a lack of proper flight planning and fuel monitoring, as the pilot underestimated the required fuel for the return leg.
- The pilot demonstrated a lack of flight discipline by providing incorrect license information on the flight plan.
- Organizational factors, including a lack of oversight by the aircraft owners, allowed for improper operational behaviors to persist.