What happened
On February 1, 2009, a Piper PA-28R-180, registration PT-DJA, was performing a scenic flight over the Pantanal region when the engine suddenly failed. The aircraft had just completed a left turn after departing from the runway 18 at the Santo Antônio do Leverger airfield (SWLV) and was at an altitude of approximately 1,200 feet.
The pilot attempted to return to the airfield for an emergency landing. However, during the approach, the pilot's management of the altitude-speed relationship was inadequate. As the pilot attempted to align with the runway, the descent rate increased significantly. Upon extending the landing gear, the aircraft lost critical altitude and struck trees and the ground approximately 100 meters from the runway threshold. The impact caused extensive damage to the aircraft, rendering it a total loss. All three occupants—the pilot and two passengers—perished; one died at the scene, while the remaining two died from their injuries two days later.
The investigation
CENIPA investigators examined the wreckage and conducted bench tests on various engine components. While the electrical fuel pump was found to be operating at only 5 PSI (well below the required 15–35 PSI), investigators determined this was not the primary cause of the engine failure.
Detailed analysis of the Servo Fuel Injector revealed a critical maintenance error. During a bench test, investigators found that the control shaft exhibited excessive lateral play and fuel leakage. Further disassembly revealed that an incorrect black packing (gasket) had been installed on the shaft instead of the blue, fuel-resistant packing specified in the Illustrated Parts Catalog (IPC). This improper part swelled and hardened upon contact with aviation gasoline, creating excessive pressure on the shaft and causing the lateral movement that led to the fuel leak and subsequent engine flameout.
Findings
- Improper maintenance: An unrecorded maintenance intervention resulted in the installation of an incorrect, non-spec packing in the servo injector, which caused fuel leakage and engine failure.
- Pilot judgment: The pilot failed to properly manage the approach, attempting to land at the runway threshold rather than the first third of the runway, and extended the landing gear at a point that made the loss of altitude irreversible.
- Maintenance oversight: The investigation noted that while the aircraft's inspections were up to date, the specific error in the servo injector assembly was not detected during the previous annual inspection.