What happened
On July 8, 2020, a Beechcraft BE 58, registration PR-OFI, was performing a ferry flight from Ubatuba to Campo de Marte Aerodrome (SBMT) in São Paulo. During the flight, the pilot reported a failure in one of the engines and requested a single-engine approach to the destination.
During the landing phase at SBMT, the aircraft touched down three times on runway 12. The pilot subsequently initiated a go-around. However, the aircraft failed to gain sufficient altitude, striking trees located beyond the runway end before impacting a public road on Braz Leme Avenue. The impact and subsequent fire destroyed the aircraft, and the pilot sustained fatal injuries.
The investigation
CENIPA's investigation focused on the mechanical failure and the pilot's decision-making during the emergency. Investigators examined the right engine and discovered that cylinder number 5 had detached from the crankcase. This was caused by the fatigue fracture of studs and through-bolts. Notably, one stud showed grooves on the threads consistent with material removal by chips.
The investigation also analyzed the aircraft's performance capabilities. Calculations indicated that under single-engine configuration, the aircraft had a very limited climb margin. While the pilot could have potentially stopped the aircraft on the runway after the initial touchdowns, the decision to execute a go-around placed the aircraft at high risk of hitting obstacles.
Findings
- The right engine failed due to a fatigue fracture of the cylinder studs and through-bolts.
- The pilot conducted an unstabilized approach at a speed higher than recommended.
- The decision to execute a single-engine go-around under marginal performance conditions was a critical factor.
- The pilot did not consider diverting to an alternate aerodrome, such as SBGR, which offered longer runways and fewer obstacles.
- Nighttime conditions and increased cockpit workload may have reduced the pilot's situational awareness.