What happened
On September 17, 2007, a BE-60 aircraft, registration PT-OOH, was operating a flight from Montes Claros to Goiânia. During the flight, the pilot reported issues with the left engine while approaching the Goiânia Terminal. Shortly thereafter, the pilot declared an emergency, stating that both engines had failed and that a forced landing was imminent.
The aircraft impacted the terrain at an elevation near Fazenda Mata do Engenho, approximately 27 NM from Goiânia. The force of the impact was so severe that the seat attachment points failed and the seatbelts broke, causing the pilot and the passenger to be thrown forward into the instrument panel. Both occupants sustained fatal injuries at the scene. The aircraft suffered extensive structural damage.
The investigation
CENIPA investigators established that the aircraft had departed Montes Claros without refueling. Although the pilot had been prompted by a fuel service employee to refuel, the pilot performed a brief calculation and decided against it, intending to deliver the aircraft to a maintenance facility with as little fuel as possible to avoid waste.
Investigation of the wreckage and fuel systems revealed that no fuel remained in the tanks, fuel lines, or any other part of the fuel system. Furthermore, while the pilot had informed air traffic control that the aircraft had two hours of endurance remaining, the investigation concluded this was an inaccurate report. The investigation also noted that the pilot's flight planning failed to account for the necessary safety margins required by regulations.
Findings
- Fuel exhaustion caused the total loss of engine power.
- The pilot made a deliberate decision to fly with insufficient fuel to avoid leaving excess fuel in the tanks at the maintenance shop.
- There was a failure in flight planning, as the pilot did not include the required safety reserves in the fuel calculations.
- The pilot demonstrated poor decision-making and a lack of situational awareness, including a delay in declaring an emergency.
- The pilot's decision-making was characterized by a disregard for established safety procedures and regulations regarding minimum fuel reserves.