What happened
On December 2, 2014, a Piper PA-25-26C, registration PT-BOW, was performing a ferry flight from Fazenda São Roque to Lins, São Paulo. Approximately 20 minutes into the flight, the aircraft experienced an engine failure followed by a total loss of power. At an altitude of approximately 500 feet, the pilot performed an emergency landing in a sugarcane plantation at Fazenda São Francisco. The pilot and the passenger both escaped the incident uninjured, and the aircraft sustained no damage.
The investigation
CENIPA investigators found that the aircraft was airworthy, with all mandatory inspections, weight and balance, and documentation up to date. However, the investigation faced significant challenges because the operator performed unauthorized inspections and fuel drainage on the aircraft before investigators arrived, thereby compromising the preservation of evidence.
While laboratory analysis of the remaining fuel and engine oil showed they met required standards, the operator reported finding a large amount of water during the unauthorized drainage. The investigation also noted that the fuel used for the flight had been transported in plastic drums from Lins to the departure site the previous day. The pilot also reported that he did not personally supervise the refueling process, which was conducted using plastic jerrycans, nor did he perform a fuel sump check prior to takeoff.
Findings
- Improper fuel handling: The use of inappropriate containers for transporting and storing fuel may have introduced contamination.
- Management and planning failures: Inadequate organizational oversight regarding fuel procurement and operational resource allocation.
- Lack of oversight: The pilot did not monitor the refueling process or perform pre-flight fuel drainage.
- Compromised investigation: The operator's unauthorized intervention at the scene hindered the collection of critical evidence, such as the contaminated fuel drained from the tanks.