What happened
On May 20, 2022, an EMB-110P1, registration PT-SHN, was performing a cargo flight from Jundiaí to Eldorado do Sul when the crew identified a malfunction in the left engine. During the descent, the pilots observed that the left engine torque would not reduce below 1,30-lb.ft.
After an initial landing attempt, the crew proceeded with a second approach. During the final approach of this second attempt, the crew elected to shut down the left engine. Following the shutdown, the aircraft entered an uncontrolled descending left turn. The aircraft struck an embankment and skidded across a rice field, sustaining substantial damage, including the severance of the left wing at the root. The pilot in command sustained serious injuries, while the second in command suffered minor injuries.
The investigation
CENIPA's investigation focused on the mechanical failure of the powerplant and the crew's decision-making process. Technical analysis of the Fuel Control Unit (FCU) revealed a fracture in the bellows caused by fatigue failure. This crack allowed the equalization of pressures (Px and Py), which effectively locked the engine power at 1,300 lb.ft.
The investigation also examined the crew's performance, noting that they did not declare an emergency to Air Traffic Control and failed to review engine failure or shutdown procedures before executing the shutdown on final approach. Furthermore, the investigation looked into the operator's compliance with training requirements and maintenance oversight.
Findings
- A fatigue-induced fracture in the FCU bellows caused the engine power to lock.
- The crew performed the engine shutdown during final approach at a low altitude, a condition that prevented the maintenance of controlled flight in a single-engine configuration.
- The crew demonstrated poor Crew Resource Management (CRM), characterized by unorganized communication and a failure to consult emergency checklists.
- The pilots' decision to continue the flight under VFR despite meteorological conditions below minimums reduced the available safety margin.
- A complacent attitude, driven by familiarity with the destination, led to inadequate adherence to safety procedures.
- The pilot in command used non-standard phraseology and lacked assertiveness, hindering the second in command's ability to react effectively.
Safety action
CENIPA recommended that ANAC coordinate with the operator, Sales Táxi Aéreo Ltda., to ensure strict compliance with the company's training program, specifically regarding mandatory CRM training for all personnel.