What happened
On November 16, 2004, at 17:33 UTC, a Cessna 210F, registration PT-CIE, was performing a ferry flight from Araçatuba to Birigui, Brazil, carrying a pilot and three passengers. Shortly after departing Araçatuba, the aircraft began maneuvering to avoid cumulonimbus clouds. During these maneuvers, the engine ceased operation approximately three minutes after takeoff. The pilot performed a forced landing on a farm near Birigui. The impact caused substantial damage to the aircraft, including the landing gear, fuselage spine, propeller, wings, elevator, and horizontal stabilizer. The pilot sustained minor injuries, while the three passengers were uninjured.
The investigation
CENIPA investigators examined the fuel system and the engine's operational state. Although the aircraft's annual maintenance inspection was expired, no mechanical defects were found in the engine or the fuel delivery systems that could have caused the failure. The investigation revealed that the fuel tanks contained unequal amounts of fuel: 10 liters in the left tank and 65 liters in the right tank. The pilot had been using the right tank but had switched the fuel selector during the emergency. However, the pilot failed to activate the electric fuel pump as required by the aircraft's emergency checklist. Additionally, the investigation noted that the landing gear remained extended during the flight due to a retraction system failure.
Findings
- Improper fuel management involving an unbalanced fuel load between the tanks.
- Failure to follow the established emergency checklist, specifically the omission of activating the electric fuel pump after switching fuel tanks.
- Inadequate flight planning and pilot judgment during maneuvers in weather involving cumulonimbi.
- The pilot was operating with an expired pilot certificate (CHT).
- The aircraft was operating with an expired annual maintenance inspection (IAM) and outdated logbook entries.