What happened
On July 2, 2002, a Twin Commander 500-S, registration PT-KZD, operated by TAF Táxi-Aéreo Ltda., departed from Pinto Martins Airport (SBFZ) in Fortaleza for a verification flight following a 50-hour inspection. Shortly after passing 200 feet, the pilot noticed a fluctuation in fuel flow and a loss of power in the left engine.
The pilot attempted to troubleshoot by cycling the engine-driven fuel pump, but the issue persisted. In an attempt to manage the failure, the pilot feathered the propeller and shut down an engine. During this process, the aircraft lost altitude and airspeed rapidly. The left wing struck a wall on top of a house, and the aircraft subsequently struck the roof of a second residence before coming to rest on the concrete slab of a third house. The aircraft was completely destroyed.
The investigation
CENIPA's investigation focused on the mechanical failures and the pilot's emergency response. Investigators examined the engine components and found significant maintenance deficiencies. Specifically, the fuel pump body was warped, allowing air to enter the fuel line, and a missing sealing ring in the fuel injection unit's integration stem allowed air into the pneumatic chamber, resulting in incorrect fuel metering.
Furthermore, the investigation looked into the organizational culture of the operator, noting a lack of systematic training and a lack of communication between maintenance and flight crews. The investigation also noted that the aircraft had a history of at least three previous in-flight engine failures.