What happened
On April 12, 2000, a BEECH 6/5-B 80, registration PT-KKI, was performing a ferry flight from Pampulha Airport (SBBH) to Sorocaba, SP, for engine maintenance. Shortly after takeoff, the left engine suffered a failure characterized by intermittent power loss and visible smoke. The pilot lost directional control, causing the aircraft to enter a steep left-hand turn. The aircraft lost altitude and impacted four houses in the São Bernardo neighborhood in a belly-first position. The impact and subsequent fire destroyed the aircraft and killed all three occupants. Two residents in the nearby houses sustained minor injuries.
The investigation
CENIPA's investigation revealed that the aircraft was flying with a canceled Certificate of Airworthiness and an expired annual inspection. The investigation found that the aircraft had been stationary without engine starts for several months prior to the accident. Maintenance records were found to be highly irregular, including unperformed tasks, services logged by unqualified personnel, and failure to follow technical service letters regarding engine preservation. Furthermore, the flight violated operational regulations (IAC 3108) by carrying two unauthorized passengers on a ferry flight intended only for technical personnel. The investigation also noted that the pilot used an unapproved portable VHF radio for air traffic communications.
Findings
- Engine Failure: The left engine failed due to insufficient lubrication, which caused the connecting rod bearings to deteriorate and seize.
- Pilot Error: The pilot failed to feather the propeller of the failed engine and executed a left-hand turn, which contradicted the aircraft manual's recommendation to turn toward the operating engine to maintain control.
- Maintenance Deficiencies: The aircraft's maintenance was inadequate, with significant non-conformities in the annual inspection and improper engine preservation.
- Human Factors: The pilot's personality, characterized by overconfidence and a disregard for safety, combined with anxiety regarding a scheduled medical appointment, influenced the decision to proceed with the flight despite the aircraft's unsafe condition.
- Operational Violations: The flight was conducted with unauthorized passengers and lacked proper supervision from the maintenance companies involved.