What happened
On April 9, 2014, a Beechcraft B200, registration PR-EDW, departed from Carajás, PA, bound for Palmas, TO. The flight was operating as a private transport mission for company employees, carrying a pilot and two passengers. During the descent phase of the flight, while cruising at FL240, the right engine ceased functioning approximately 80NM from the destination. As the aircraft continued its descent and crossed FL140, the left engine also failed, leaving the aircraft without power.
The pilot was forced to execute a glide to an emergency landing at Fazenda Bacaba, in Miranorte, TO. The landing took place on an uncertified, unregistered airstrip. Despite the severity of the dual engine failure, the aircraft sustained no damage, and all three occupants escaped the scene uninjured.
The investigation
CENIPA's investigation focused on the fuel management and flight planning of the aircraft's multiple flight segments throughout the day. The investigation tracked the aircraft's movements from its last refueling in Pium, TO, through several legs involving Marabá and Carajás.
Investigators examined the fuel quantities recorded in the logbooks and compared them against the performance charts in the Airplane Flight Manual (AFM). The investigation established that while the aircraft had been fueled with a significant amount of fuel earlier in the day, it was not replenished during subsequent stops in Palmas, Marabá, or Carajás. The investigation also reviewed the pilot's planning process, noting that the pilot did not perform a detailed fuel calculation using the performance section of the manual for the final leg and failed to account for wind and known meteorological conditions.
Findings
- The primary cause of the engine failures was fuel exhaustion, as the engines stopped due to the total depletion of usable fuel in the tanks.
- The flight was conducted in violation of RBHA 91.167 regulations, which require sufficient fuel to reach the destination, fly to the alternate, and maintain a 45-minute reserve.
- Inadequate flight planning, specifically the failure to calculate required fuel for the final leg.
- Errors in pilot judgment regarding fuel requirements.
- Lack of managerial oversight regarding flight operations.