What happened
On March 14, 2007, an Aero Commander 500S, registration PP-SEC, operated by Bahia Táxi Aéreo Ltda, crashed in São Sebastião do Passé, Bahia, during a flight from Petrolina to Salvador. The aircraft was performing a mail transport mission with four people on board.
Approximately one hour and 32 minutes into the flight, the pilot notified Salvador Approach (APP-SV) of an engine failure. While attempting an emergency landing in an open field—after being unable to use a nearby road due to vehicle traffic—the pilot lost control of the aircraft. The plane entered a steep right turn and a nose-down attitude, resulting in a stall and impact. The collision destroyed the aircraft, and all four occupants (two crew members and two passengers) died at the scene.
The investigation
CENIPA's investigation revealed a series of systemic failures regarding flight planning and operational oversight. Investigators found that the pilot had been using inaccurate fuel consumption data, recording 100 l/h instead of the actual 120 l/h average. Furthermore, the pilot's logbook entries for flight times were inconsistent, leading to an erroneous calculation of remaining fuel. This resulted in the aircraft departing with significantly less fuel than required for the planned legs.
During the emergency descent, the investigation established that the right engine, which had failed, was not feathered. This failure to feather the propeller increased aerodynamic drag, making the aircraft harder to control. Additionally, the investigation noted that the co-pilot's medical certificate and flight qualifications were expired, and the company's oversight of flight planning and fuel records was insufficient.
Findings
- Inadequate flight planning due to the use of incorrect fuel consumption rates and inaccurate flight time logging.
- Failure to feather the engine following the power loss, which increased drag and contributed to the loss of control.
- Pilot error during the emergency approach, specifically regarding improper control inputs that led to a stall.
- Organizational deficiencies within the operator, including a lack of effective supervision, inadequate fuel management procedures, and a weak safety culture.
- Inaccurate fuel gauging caused by a fueling process that could create air bubbles, combined with an unreliable fuel quantity indicator.