What happened
On May 24, 2015, an EMB-820C Carajal, registration PT-ENM, operated by Mato Grosso do Sul Taxi Aéreo Ltda, was performing a passenger transport flight from Estância Caimam to Campo Grande, Brazil. During the descent phase, approximately 43 nautical miles from the destination, the left engine failed due to fuel exhaustion.
Unable to maintain altitude with the remaining engine, the crew performed an emergency landing in a field at Fazenda Palmares, in the municipality of Rochedo. While the two pilots and seven passengers sustained minor injuries, the aircraft suffered substantial damage to its engines, propellers, wings, and fuselage underside.
The investigation
CENIPA's investigation revealed that the left engine failed because the fuel tank in the left wing had run dry, despite the cockpit instruments indicating available fuel. Investigators discovered that the fuel level sensors in the left wing had been installed incorrectly (inverted), which caused the gauges to show a higher fuel quantity than was actually present. Additionally, a continuity failure was found in the connector plug of the right-side fuel sensor.
The investigation also identified that the aircraft was not in an airworthy condition at the time of departure, as the Cockpit Voice Recorder (CVR) and the automatic propeller feathering system were inoperative. Furthermore, the crew did not follow the established emergency checklists for engine failure, failing to properly feather the propeller, which degraded the aircraft's single-engine climb performance.
Findings
- Inverted fuel sensors in the left wing led to inaccurate fuel quantity indications, resulting in the left engine running out of fuel.
- Improper emergency procedures were executed, as the crew failed to follow the checklist for engine failure and did not properly feather the propeller.
- Organizational culture prioritized economic objectives over safety, leading to a normalization of deviations, such as the lack of standardized pre-flight inspections and checklists.
- Maintenance and training deficiencies were present, including the use of aircraft types for training that differed from the company's official program and a lack of documented inspections for the fuel system sensors.
- Inadequate management supervision allowed the crew to plan flights and manage operational routines without sufficient oversight from the operator.