What happened
On February 8, 2012, a Beechcraft F90, registration PT-OFD, was conducting a flight from Congonhas (SBSP) to Belém (SBBE) with two pilots and two passengers. During the approach to runway 06 at Belém, the aircraft experienced a critical sequence of failures: one engine flamed out, followed minutes later by the failure of the second engine.
Unable to maintain flight, the crew performed a ditching in the waters of Guajará Bay, approximately 1,200 meters short of the runway threshold. The aircraft remained submerged for twelve days, causing substantial damage to the airframe and electronic equipment. All four occupants were rescued by Brazilian Navy personnel from the nearby Val de Cans Naval Base. While two passengers and one pilot escaped uninjured, the second pilot sustained minor injuries.
The investigation
CENIPA's investigation focused on the decision-making process regarding fuel management and the operational status of the aircraft. Investigators found that the aircraft's fuel quantity and fuel flow indicators were providing unreliable information. Furthermore, the investigation revealed that while the aircraft was registered to Mônaco Diesel Caminhões e Ôprees Ltda., it had been purchased by a private individual and was being prepared for incorporation into the fleet of Tail Taxi-Aéreo Ltda., though the ownership transfer had not yet been recorded in the Brazilian Aeronautical Registry.
Findings
- Fuel exhaustion was the primary cause of the engine flame-out.
- The pilot in command demonstrated overconfidence by deciding to proceed non-stop to the destination despite malfunctioning fuel gauges and the decision to bypass a refueling stop in Palmas.
- The crew failed to plan for sufficient reserves, neglecting to account for the fuel required to reach an alternate airport plus a 45-minute reserve.
- The copilot exhibited a lack of assertiveness by failing to challenge the captain's decision to fly without a refueling stop.
- There were discrepancies in the flight plan, which stated the transport of a sick person, though no patient was actually on board at the time of the accident.
- The aircraft was being operated for a type of service (private air services) for which the operator was not certified.