What happened
On May 5, 2006, a 500S Shrike Commander, registration PT-IGL, was performing a flight from Recife to Natal, Brazil, to transport bank mail. While executing a VOR approach to runway 16L at Natal (SBNT), the left engine failed. Shortly after, at approximately 600 feet above the ground, the right engine also failed.
The pilot attempted an emergency landing in an unprepared field near Jacaraú. Upon initial contact with the ground, the aircraft slid for 200 meters, struck a tree with the left wingtip, and veered 90 degrees before coming to a stop. The pilot and one passenger sustained minor injuries, but the aircraft suffered substantial damage to the fuselage and left wing.
The investigation
CENIPA investigators determined that the engine failures were caused by fuel exhaustion. While the aircraft had been fueled the previous night with an amount intended to exceed the calculated consumption for the leg, the investigation found that the aircraft's fuel quantity indicators (float gauges) were inoperable. This prevented the crew from verifying the actual fuel remaining in the tanks during pre-flight inspections.
Investigators also explored the possibility of fuel theft, noting that the aircraft's design allowed for easy access to fuel drains and that informal reports of fuel theft existed at the departure airport. However, this could not be confirmed due to the faulty gauges. The investigation also highlighted significant discrepancies in flight logs, noting that weight and balance and fuel data were often imprecise.
Findings
- Fuel starvation was the primary cause of the dual engine failure.
- An organizational culture within the operator allowed for informal fueling methods that did not meet minimum safety requirements for flight autonomy.
- Inadequate pilot training resulted in a lack of proper fuel management skills required for air taxi operations.
- Deficiencies in flight planning and management oversight led to the use of unreliable flight records and the operation of an aircraft with inoperable fuel gauges.
- Inadequate managerial supervision failed to identify operational flaws in fuel management and flight planning processes.