What happened
On September 20, 2013, an EMB-810D aircraft, registration PT-VRF, was performing a flight from Ouro Fino, MG, to Caldas Novas, GO, with a scheduled technical stop for refueling. The flight was part of a larger journey intended to reach Gurupi, TO.
During the final approach to the Caldas Novas Aerodrome, both engines failed simultaneously due to fuel exhaustion. The loss of power caused the aircraft to become unstable in flight, leading to a collision with the ground approximately 760 meters from the runway threshold. The impact resulted in the destruction of the aircraft and the deaths of the pilot and all four passengers.
The investigation
CENIPA's investigation focused on the sequence of events leading to the fuel starvation. Investigators examined the aircraft's fuel system, which utilized interconnected tanks across both wings. The investigation also reviewed the pilot's operational history, noting that the pilot had previously operated flights with fuel reserves below the regulatory minimums required by RBHA 91.151.
Records indicated that the aircraft had departed Ouro Fino without the ability to refuel at that location, necessitating the stop in Caldas Novas. The investigation also looked into the pilot's decision-making process regarding the flight plan and the management of fuel reserves during the leg from Ouro Fino to Caldas Novas.
Findings
- Fuel exhaustion was the primary cause of the dual engine failure.
- The pilot demonstrated a complacent attitude regarding regulatory fuel reserve requirements, with evidence of a recurring pattern of arriving at destinations with insufficient reserves.
- Inadequate flight planning and decision-making led to the selection of a refueling stop that left the aircraft with insufficient margins.
- The pilot's inability to properly apply control inputs following the second engine failure contributed to the loss of control and prevented an emergency landing.
- There was evidence of flight indiscipline regarding the intentional non-compliance with established fuel minimums.
- The pilot's perception of the risks associated with low fuel levels was inaccurate, particularly regarding the reaction time required during a fuel starvation event.