What happened
On February 2, 1999, a Britten-Norman BN-2A-9, registration PT-KNM, was parked at the Aeroclube de Rondônia airfield in Porto Velho, Brazil. The aircraft was prepared for a scheduled flight to Lábrea, Amazonas, carrying one passenger and a cargo of food supplies.
During the attempt to start the left engine, a fire broke out. The pilot performed several consecutive start attempts without observing the mandatory waiting intervals specified in the aircraft manual, which are required to allow excess fuel to drain and to prevent the starter motor from overheating. The fire quickly spread from the left engine to the left wing and eventually consumed the entire aircraft. The pilot and the passenger were able to abandon the aircraft through the single left-side door and escaped without injuries, but the aircraft was a total loss.
The investigation
CENIPA's investigation revealed a significant breakdown in aviation safety standards involving the pilot, the operator, and the airfield infrastructure. The investigation established that the pilot was not qualified to operate a multi-engine aircraft and lacked the necessary technical rating for the category of operation. Furthermore, the aircraft's airworthiness certificate had been canceled, and its annual maintenance inspection was several years overdue.
Investigators found that the aircraft had been withdrawn from a maintenance facility without the completion of necessary works and lacked proper maintenance logs. The investigation also noted that the airfield lacked an Aeronautical Emergency Plan (PEAA), had no firefighting services, and lacked fire extinguishers available for use during engine start procedures. The pilot's psychological profile was also examined, revealing an overconfidence and a disregard for regulatory standards in favor of economic interests.
Findings
- The fire was caused by improper engine start procedures, specifically repeated attempts without the required cooling and fuel drainage intervals.
- The pilot lacked the proper multi-engine rating and qualification for the aircraft type.
- The aircraft was in an unairworthy condition, with a canceled certificate and overdue maintenance inspections.
- The operator failed to provide adequate supervision, allowing an unqualified pilot to operate the aircraft.
- The airfield lacked essential emergency infrastructure, including firefighting personnel, an emergency plan, and available fire extinguishers.
- The pilot's excessive self-confidence and disregard for safety regulations contributed to the operational risks.