What happened
On May 30, 2000, a BEECH F-90, registration PP-EFC, departed from an uncertified airstrip at Fazenda Itapuranga, Goiás, bound for Goiânia. The aircraft was carrying two pilots and seven passengers. Approximately 10 minutes into the flight, while at cruise altitude, the right engine failed. The crew continued the flight in single-engine mode, intending to complete the short leg to Goiânia. However, during the final approach to the destination, the remaining left engine also failed. The pilots were forced to perform an emergency landing in a clearing, where the aircraft struck trees before hitting the ground. The impact caused extensive damage to the airframe, including the engines, propellers, wings, and fuselage, rendering the aircraft a total loss.
The investigation
CENIPA investigators determined that the primary cause of the dual engine failure was fuel exhaustion. Post-accident inspections of the PT6A-2 and PT6A-28 engines revealed that the fuel pumps had been operating dry, causing internal wear to the pump components. While the fuel system itself showed no leaks, the fuel tanks were found to be empty upon investigation.
The investigation also highlighted that the aircraft's fuel quantity indicators (liquidometers) were defective and unreliable, a condition known to the aviation authority. Furthermore, the investigation scrutinized the crew's decision-making process, noting that the commander had estimated the remaining fuel was sufficient without verifying the actual quantity, and the co-pilot had failed to assertively communicate his concerns regarding the need for refueling.
Findings
- Fuel Exhaustion: The engines stopped because the aircraft ran out of fuel during flight.
- Inadequate Planning: The crew failed to perform an accurate fuel calculation and did not verify the actual fuel on board before departure.
- Deficient Crew Resource Management (CRM): There was a lack of effective communication and coordination between the pilot and co-pilot, exacerbated by underlying interpersonal conflicts and a lack of assertiveness from the co-pilot.
- Organizational Failures: The operating organization lacked a robust safety culture, allowing the use of aircraft with unreliable fuel gauges and permitting non-standard operational procedures.
- Maintenance and Supervision: The organization failed to ensure standardized fuel control procedures and did not address the known unreliability of the fuel quantity indicators.