What happened
On November 6, 2012, a PA-31T2 aircraft, registration PT-MFW, was performing a valuables-transport flight from SBDO to SBBI. While on final approach for landing on runway 18 at Bacacheri Aerodrome, the aircraft struck a 30-meter tall pine tree, which caused the left wing to impact the vegetation. The aircraft then collided with a second tree, rupturing the right wing tip tank. The aircraft subsequently crashed into the ground in a steep, 60-degree pitch-down attitude. The impact resulted in four fatalities, including both crewmembers and two passengers. The aircraft was completely destroyed.
The investigation
CENIPA's investigation established that the accident was caused by fuel exhaustion. Investigators found that the aircraft's fuel gauges were not providing accurate readings, which significantly impaired the crew's situational awareness regarding remaining fuel. The investigation also revealed that the crew did not properly evaluate the fuel required for the flight leg. Furthermore, the company's operational culture lacked rigorous fuel record-keeping, often relying on approximate calculations from previous flights. The investigation noted that the crew's decision-making was likely influenced by the complexity of the mission and a lack of standardized refueling procedures.
Findings
- Fuel starvation/exhaustion was the primary cause of the accident.
- The crew failed to properly analyze the fuel requirements for the flight leg between SBDO and SBBI.
- The aircraft's fuel quantity indicators were malfunctioning, providing incorrect information to the pilots.
- A lack of organizational oversight meant the company did not enforce standardized flight planning or minimum fuel requirements in mission orders.
- The company's work culture relied on unreliable, approximate fuel calculations rather than precise monitoring.
- Operational pressures and a lack of effective supervision contributed to the crew's failure to adhere to standard operating procedures.