What happened
On July 21, 2016, at 16:55 UTC, a Piper PA28A, registration PT-IYQ, was performing a local flight for private pilot instruction at the Bacacheri Aerodrome (SBBI) in Curitiba, Brazil. The aircraft was operated by Aeroclube do Paraná with an instructor and a student pilot on board.
Following takeoff from runway 36, the aircraft experienced a loss of engine power moments after rotation. The instructor managed to land the aircraft on the runway, but the aircraft failed to stop before the end of the paved surface, eventually coming to a halt on the grass. There were no injuries to the crew and no damage was sustained by the aircraft.
The investigation
The investigation established that the engine did not stall, but rather suffered a significant power deficiency. Upon returning to the hangar, a mechanic noticed a fuel leak at the front of the aircraft. Subsequent inspection revealed that the fuel filter drain had been left open. This drain had been used during the pre-flight inspection earlier in the day but was not closed following the procedure.
The investigation also found that while the student pilot performed the initial pre-flight inspection, the instructor's follow-up inspection failed to identify the open drain. The investigation noted a lack of formal, written procedures at the flight school regarding the specific assignment of responsibilities for pre-flight inspections, leading to an ambiguity in roles between the instructor and the student.
Findings
- The open fuel filter drain caused a continuous fuel supply deficiency to the carburetor, resulting in the loss of power during the takeoff roll.
- Pilot oversight regarding the completion of the fuel drainage procedure.
- Ambiguity in crew responsibilities due to the absence of written procedures defining which crew member is responsible for specific pre-flight inspection tasks.
Safety action
At the time of the report's publication, the following recommendations were issued to the National Civil Aviation Agency (ANAC):
- Work with Aeroclube do Paraná to reinforce the importance of strict adherence to operational procedures and checklists.
- Ensure the flight school establishes a clear definition of responsibilities for crew members regarding pre-flight inspections.