What happened
On November 30, 2018, a Cessna 210N, registration PR-JEE, departed from Campo de Marte Airport (SBMT) in São Paulo, Brazil, bound for Jundiaí. The flight was intended as a ferry flight for preventive maintenance. Shortly after takeoff, the aircraft failed to establish a positive climb gradient and instead entered a descending left-hand turn. The aircraft subsequently collided with a residential building in the Casa Verde neighborhood.
The impact destroyed the aircraft and caused significant damage to the struck residence and neighboring houses due to fire. The wreckage also ignited several vehicles and a garbage truck parked on the street. The two fatalities involved were the pilots on board.
The investigation
CENIPA investigators examined the wreckage and engine components, noting that the aircraft's maintenance logs were destroyed in the fire. However, investigators recovered a recent service order from October 2018 and a compression test record from late November 2018. Analysis of the engine revealed that while the engine was operational, several cylinders exhibited compression levels at or slightly below the minimum acceptable limits.
Furthermore, investigators found carbonization on the fuel injector of cylinder number 3, as well as on the spark plugs and combustion chambers of cylinders 1 and 3. The presence of a non-AvGas liquid was also detected in one of the fuel capillary tubes. While the fuel from the supplier was found to be uncontaminated, the investigation considered the possibility of water accumulation in the tanks due to heavy rain the previous day.
Findings
- The engine was likely operating with degraded performance due to low compression in several cylinders and carbonization in critical components.
- The crew may have failed to adequately assess the engine's operational condition during ground checks or during the takeoff roll.
- There was a possibility of inadequate maintenance procedures that failed to detect pre-existing engine degradation.
- The pilots did not appear to perceive the engine's performance deficiency, which led them to proceed with the takeoff despite the increased runway usage.