What happened
On May 8, 2010, a Cessna 150E, registration PT-BXF, was conducting a flight training mission departing from Salvador, Bahia. The aircraft had already completed a prior flight of 80 minutes without being refueled. During the second flight, approximately 34 minutes into the mission, the engine began to experience intermittent power loss while the aircraft was near the Arembe-be beach.
Upon noticing fluctuations in engine oil pressure and temperature, the instructor took control of the aircraft. After notifying air traffic control of the emergency, the instructor performed a forced landing on a sandy area of the beach. Both occupants of the aircraft escaped without injury, and the aircraft sustained no damage.
The investigation
CENIPA investigators determined that the left fuel tank had been depleted, while the right tank remained full. The investigation revealed that the fuel selector valve was set to the "Left" position, which had caused the engine to draw only from the exhausted tank.
Investigators found a significant discrepancy in the aircraft's hardware: the installed fuel selector valve had a different part number than the one specified in the manufacturer's parts catalog. Furthermore, there was a mismatch between the aircraft's manual and its checklist regarding the valve's positions. The investigation also uncovered that the instructor had not supervised the student's pre-flight checklist execution because he was preoccupied with debriefing a previous flight. Additionally, a culture of informal procedures existed within the flight school, where instructors used unstandardized, informal rules for fuel management between flights.
Findings
- Fuel exhaustion caused by the depletion of the left tank while the selector remained on the left position.
- Inadequate crew coordination and task management, as the instructor failed to supervise the student's pre-flight checks.
- Use of an incorrect, non-standard fuel selector valve that did not match the manufacturer's specifications.
- Incompatibility between the aircraft's operating manual and the onboard checklist.
- An organizational culture characterized by informal operational rules and a lack of standardized training supervision.
- Low situational awareness by the instructor, who relied on habit rather than active verification of critical checklist items.