What happened
On May 19, 2020, a Neiva EMB-810D, registration PT-VEH, departed from the Tietê Aerodrome (SDET) in São Paulo, Brazil, bound for Penápolis. The flight was a ferry operation intended to transport the aircraft for maintenance. The crew consisted of the pilot and one passenger.
Shortly after takeoff, the aircraft performed a low pass over the runway to verify the landing gear status. Following this maneuver, the aircraft turned left and entered a wind leg, where it lost altitude and struck the ground. The impact and subsequent fire destroyed the aircraft, and both the pilot and the passenger sustained fatal injuries.
The investigation
CENIPA investigators examined the wreckage and maintenance records, uncovering significant irregularities. The aircraft's Airworthiness Certificate had been expired since February 2016, and maintenance logs for the airframe, engines, and propellers were not up to date. Although a Special Flight Permit (AEV) had been issued by ANAC, investigators found that the maintenance organization had requested the permit before the required maintenance services were actually performed.
Technical analysis of the engines by the DCTA revealed critical fuel system defects. On the right engine, a nut connecting the fuel capillary tube to the number 4 cylinder injector was loose and lacked proper torque. On the left engine, the fuel capillary tube connecting the distributor to cylinder number 2 was ruptured due to corrosion and porosity at the brazing interface. Both defects were capable of causing power loss or engine failure by restricting fuel flow.
Analysis of the propellers indicated that the left engine was inoperative at the time of impact, while the right engine was producing low power. Furthermore, the passenger's presence on board violated the conditions of the Special Flight Permit, which did not authorize passengers for this ferry operation.
Findings
- Engine fuel delivery failure due to improper maintenance and lack of adequate supervision.
- Inadequate maintenance oversight regarding the execution of services prior to flight.
- The aircraft was operating with an expired Airworthiness Certificate.
- Improper engine preservation procedures following a long period of inactivity.
- Presence of an unauthorized passenger on a ferry flight.