What happened
On January 10, 2009, an EMBRAER EMB-711C, registration PT-NEE, departed from Aeródromo General Leite de Castro in Rio Verde, Goiás, for a local flight. Shortly after takeoff, once the landing gear had been retracted, the pilot noticed a rapid and progressive loss of engine power. Upon checking the fuel flow indicator, the pilot observed that the flow rate was below normal levels.
Faced with the engine failure, the pilot executed an emergency landing on the BR 060 highway. The aircraft came to a stop near a service station at kilometer 388 of the road. The landing gear had not been extended prior to impact, resulting in damage to the propeller and the lower fuselage. Both the pilot and the passenger were uninjured.
The investigation
The investigation focused on determining why the engine failed during the initial climb. While bench tests confirmed that the mechanical and electrical fuel pumps, magnetos, and fuel injectors were functioning correctly, investigators discovered that the connections for the hose feeding the fuel distributor valve and the hose capturing fuel pressure for the flowmeter were nearly loose. This allowed fuel to leak, causing the power loss.
Further examination of maintenance records revealed that the engine had been removed and reinstalled during an annual inspection in September 2008. Interviews with the maintenance personnel revealed that the connections had been tightened manually without using the proper tools to reach the manufacturer's specified torque. It is believed that engine vibrations caused these improperly secured connections to loosen during flight.
Additionally, the investigation found that the pilot was operating the aircraft with an expired single-engine land (MNTE) rating and an expired medical certificate. The investigation also noted that the failure to extend the landing gear during the emergency landing likely contributed to the damage sustained by the aircraft.
Findings
- Improper maintenance of the fuel system connections, which were not torqued to specification.
- Inadequate maintenance execution and lack of proper inspection by the quality supervisor.
- The pilot was not properly qualified for the flight due to expired ratings and medical certification.
- Possible lapses in pilot memory/procedure, as the landing gear was not deployed during the emergency.
- Potential weaknesses in organizational management and technical supervision processes.