What happened
On July 3, 2017, a Cessna 210M, registration PR-MFR, was performing a scheduled flight from Pous/da Águia Aerodrome to Uaicas Aerodrome in the state of Roraima, Brazil. The aircraft was operated by Paramazônia Air Taxi Ltd. and was carrying a pilot and four passengers.
Shortly after takeoff, the aircraft experienced a loss of power and was unable to maintain a positive rate of climb. During the struggle to maintain altitude, the aircraft's left horizontal stabilizer struck a tree, which caused the left elevator to detach from the airframe. The aircraft subsequently crashed into the ground, where a post-impact fire erupted. The accident resulted in four fatalities (the pilot and three passengers) and one serious injury to a passenger. The aircraft was destroyed.
The investigation
CENIPA's investigation focused on the mechanical state of the powerplant and the operational procedures used during the flight preparation. Investigators found that the engine was operating with significantly degraded performance. Specifically, the fuel distributor filter screen was partially blocked by lead dust, several exhaust valves were leaking, and multiple hydraulic tappets were excessively worn.
Furthermore, the investigation revealed that the aircraft was configured with flaps in the 0º (retracted) position for takeoff, rather than the 10º position more suitable for the runway conditions. The investigation also noted that the passengers had boarded the aircraft while the engine was already running, a practice that increased the pilot's workload and contributed to the rushed environment.
Findings
- Engine failure in flight due to degraded performance caused by a partially blocked fuel filter and leaking exhaust valves.
- Improper flap configuration, as the flaps were retracted instead of set to 10º, which increased the required takeoff distance.
- Organizational culture weaknesses, characterized by informal maintenance practices and the use of verbal rather than written reports for aircraft discrepancies.
- Inadequate maintenance oversight, including the failure to monitor engine trends and the reliance on trust rather than documented logbook entries for repairs.
- Poor operational judgment, evidenced by boarding passengers with the engine running to reduce ground time, which likely contributed to the pilot's failure to properly configure the aircraft for takeoff.