What happened
On September 7, 2017, a Cessna T210L, registration PT-KKK, was performing a flight from Oriximiná to Piquiatuba, Brazil, to transport medical personnel and passengers. During the flight, the pilot encountered an engine issue approximately ten minutes before the scheduled arrival. While the engine initially continued to produce power, the pilot diverted the flight to Santarém (SBSN). Shortly after switching the fuel source from the left tank to the right tank, the engine lost all power. The crew and three passengers were forced to perform an emergency landing (ditching) on the Tapajós River near Praia do Carapari. All four occupants survived the impact without injury, though the aircraft sustained substantial damage.
The investigation
CENIPA's investigation revealed that the aircraft was not included in the operator's operational specifications and was being used for a private flight managed by members of a taxi-aereo company. The investigation found that the flight path had been significantly extended beyond the original plan, including unauthorized trips to an unregistered landing strip at Aldeia Mapuera. Furthermore, the aircraft had been refueled using two 50-liter containers carried irregularly on board, which violated safety regulations regarding the transport of flammable substances.
Investigators noted that while the fuel sampled from the left tank met quality standards, the right tank contained only residual fuel. The pilot's decision to switch to the nearly empty right tank resulted in the engine flameout after only five minutes of flight. Maintenance inspections of the engine found no internal mechanical defects, but internal corrosion was noted in the fuel system accessories, likely caused by the aircraft being submerged in the river.
Findings
- Improper fuel management: The pilot failed to adequately assess the remaining fuel levels after switching tanks, leading to total engine failure.
- Irregular refueling practices: The use of unauthorized containers to transport fuel on board violated safety regulations.
- Organizational culture: A lack of adherence to safety standards was evident, characterized by flight indiscipline and the use of unregistered aerodromes.
- Decision-making errors: The pilot's judgment regarding fuel reserves and the decision to fly extended routes without a flight plan contributed to the accident.