What happened
On February 19, 2014, a T210L, registration PR-VPI, departed from the Araguaína Aerodrome in Tocantins, Brazil, for a local flight. Shortly after takeoff, at an altitude between 400 and 500 feet, the aircraft suffered an engine failure.
The pilot attempted to restart the engine in flight and executed a left-hand turn. After completing nearly 180 degrees of the turn without successfully restarting the engine, the pilot performed a forced landing into a residential neighborhood. The aircraft struck a small tree before impacting the side of a house, causing significant structural damage to the building. During the impact, the left wing struck four people on the ground: a young man and three children. The impact resulted in one fatality (a child), one serious injury (another child), and two minor injuries.
The pilot sustained serious injuries, and the aircraft suffered substantial damage to the engine, propeller, landing gear, wing structure, and forward section.
The investigation
CENIPA's investigation focused on the pilot's emergency management and the mechanical failure. Investigators found that the pilot's attempt to restart the engine in flight and the subsequent 180-degree turn were not recommended by the Cessna T210L emergency checklist for an engine failure occurring immediately after takeoff.
While the pilot claimed difficulty visualizing the terrain due to the aircraft's high-wing configuration and the position of the instrument panel, investigators determined that the pilot's decision-making and flight path—specifically the premature left turn—were the primary factors affecting visibility and situational awareness. The investigation also looked into the possibility of a foreign object obstructing the fuel selector valve, though a definitive cause for the engine failure remained undetermined.
Findings
- Inappropriate emergency procedures: The pilot attempted an engine restart and executed a turn that contradicted the manufacturer's emergency checklist for this specific failure scenario.
- Loss of situational awareness: The pilot's fixation on restarting the engine prevented the evaluation of better landing alternatives, such as an open field ahead.
- Improper judgment and attitude: An elevated level of self-confidence and reliance on previously successful (but incorrect) procedures led to inadequate risk management.
- Inaccurate memory of procedures: The pilot relied on memorized procedures that did not align with the aircraft's official manual.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to:
- Ensure oversight of the maintenance facility involved to prevent the introduction of foreign objects into aircraft fuel systems.
- Ensure the operator utilizes only pilots who have received adequate training, specifically regarding engine failure procedures.