What happened
On November 21, 1998, a Cessna 170B, registration PT-AQI, was performing a ferry flight from Sorocaba, SP, to Jacarepaguá, RJ, with a scheduled stop at the Itanhaém Aerodrome in São Paulo. After refueling at Itanhaém, the pilot initiated a takeoff that witnesses described as an "special" maneuver. Immediately after leaving the ground, the aircraft assumed an extremely steep pitch angle, climbing aggressively to approximately 300 feet while still over the runway.
At the peak of this climb, the engine suffered a loss of power. In an attempt to return to the runway, the pilot executed a steep right-hand turn. Due to the low airspeed and the loss of power, the aircraft lost lift and entered a nose-down attitude, impacting the sandy terrain of the aerodrome. The impact caused the aircraft to explode and catch fire, resulting in the fatal death of the pilot and the total destruction of the aircraft.
The investigation
CENIPA investigators examined the wreckage and the engine, which was a Continental O-300-A. While the propeller showed signs of impact without power, internal inspections of the engine valves and components revealed no mechanical failure. The investigation also considered the aircraft's fuel system, which relies on gravity feed without auxiliary pumps.
Investigators evaluated the possibility of fuel starvation caused by the high pitch angle. Because the fuel tanks are located in the wings, an extreme nose-up attitude could have placed the fuel level at or below the engine level, disrupting the gravity-fed flow. This hypothesis was deemed the most probable cause of the power loss. Additionally, the investigation reviewed the pilot's decision-making, noting that the pilot had expressed intentions to perform an unusual takeoff to a witness prior to the accident.
Findings
- Improper Flight Maneuvers: The pilot deliberately operated the aircraft with an aggressive pitch angle and low airspeed, violating standard operating procedures.
- Fuel Starvation: The extreme pitch angle likely compromised the gravity-fed fuel system, leading to a loss of engine power.
- Poor Decision-Making: The pilot attempted a steep return to the runway instead of opting for a forced landing straight ahead, which would have been safer given the low altitude.
- Psychological Factors: An attitude of overconfidence and improvisation influenced the pilot's decision to perform an unauthorized maneuver.
Safety action
- The operator, JOB Propaganda Aérea Ltda., was directed to conduct pilot retraining focusing on technical knowledge of their fleet.
- The company was required to implement a training program specifically addressing normal and emergency procedures, with an emphasis on engine failure at low altitudes.
- Safety inspections were mandated to ensure compliance with these recommendations.