What happened
On 26 April 2013, a Cessna 210L, registration PR-LJI, was performing a flight from Chaves (SISO) to the Brigadier Protásio de Oliveira Aerodrome (SBJC) in Belém, Brazil. The aircraft was carrying a pilot and seven passengers, including two infants.
While the aircraft was established in the traffic pattern for landing at SBJC, the engine lost power. The pilot declared an emergency with the control tower and performed a forced landing in a grassy area near the intersection of Júlio César and Pedro Álvares Cabral avenues. The impact occurred at a pitch-down angle of approximately 20 degrees. The accident resulted in two fatalities (the pilot and one passenger), two serious injuries, and four minor injuries.
The investigation
CENIPA investigators examined the wreckage and the engine's fuel feed system. During the disassembly of the engine, no mechanical abnormalities, fractures, or fatigue were found in the internal components. However, investigators noted the absence of fuel in the fuel hoses.
While the aircraft had been refueled prior to the flight, the investigation focused on the fuel management. The aircraft's left wing tank was found to be empty, while at least 80 liters of fuel remained in the right wing tank. The investigation also noted that the operator used a non-homologated measuring rod to estimate fuel quantities, which could lead to inaccuracies in determining the exact amount of fuel on board.
Findings
- The primary cause of the engine failure was fuel exhaustion in the active tank.
- The pilot likely failed to switch fuel tanks between the outbound and return legs of the flight, or failed to switch tanks during the flight, leading to the depletion of the left tank.
- The operator lacked a formal recurrent training or operational monitoring program for its pilots.
- An informal procedure existed within the company regarding tank selection, which may have contributed to the error.