What happened
On June 22, 2022, a Cessna 1SB2P, registration PT-ILH, departed from Chácara Paraíso Aerodrome (SNYP) in Benevides, Pará, bound for Belém. The aircraft was operating a private flight with one pilot and one passenger on board. During the initial climb phase, the aircraft suffered a sudden loss of engine power. The pilot responded by performing a forced landing in a grassy area at Fazenda Madressilva, approximately 1.8 nautical miles from the departure runway threshold.
Upon touchdown, the aircraft traveled 66 meters across the terrain. The impact caused the nose landing gear strut to fail structurally, leading the nose of the aircraft to strike the ground. The aircraft sustained substantial damage to the nose gear, propeller assembly, engine nacelle, air exhaust duct, and carburetor air intake manifold. The pilot and passenger were uninjured.
The investigation
CENIPA investigators examined the engine, fuel, and maintenance records to determine the cause of the power loss. While the fuel was found to be free of contamination, the investigation revealed significant discrepancies regarding the aircraft's engine components.
Investigators discovered that the carburetor installed on the engine was an unapproved part; its internal components did not match the manufacturer's specifications, and the identification plate appeared to be improvised. Furthermore, testing of the electrical system revealed that the magneto timing was incorrect and the left magneto was malfunctioning. Inconsistent sparking was also observed in the lower spark plugs. The investigation concluded that the aircraft's airworthiness status could not be validated due to these technical discrepancies.
Findings
- The primary contributing factor was inadequate aircraft maintenance, characterized by a failure to follow manufacturer technical instructions and regulatory requirements.
- The carburetor was identified as an unapproved part with internal failures and evidence of fuel leakage.
- Improper magneto timing and malfunctioning spark plugs contributed to reduced engine efficiency.
- There was a lack of proper oversight by the aircraft owner/operator regarding maintenance tasks delegated to third parties.
- The engine was not producing power at the time of impact, as evidenced by the position of the propeller blades.