What happened
On September 15, 1990, a BEECH 65-B-8SO, registration PT-LGE, was performing a cargo and passenger flight between Uaicas and Pião in Roraima, Brazil. During the initial leg of the flight, the aircraft's right engine failed, forcing the pilot to perform an emergency landing at the Sítio da Velha airstrip in Alto Alegre.
Following the landing, the pilot drained the fuel tanks and concluded there was sufficient fuel to continue the mission. A passenger, acting as a mechanic, performed a brief visual inspection and manual rotation of the engine, declaring it functional. During the first takeoff attempt from Sítio da Velha, the right engine failed again. After one passenger disembarked, the pilot attempted a second takeoff without any further mechanical inspection or troubleshooting.
Shortly after liftoff, the aircraft climbed to approximately 200 feet before yawing to the right and losing altitude. A witness observed the aircraft performing a left-hand turn with an increasing bank angle and a steep descent, eventually impacting the ground at a high angle of attack and exploding upon impact.
The investigation
CENIPA's investigation focused on the mechanical state of the aircraft and the pilot's decision-making process. Investigators found that the aircraft's annual maintenance inspection was overdue. While the left fuel tank exploded upon impact, the right tank remained intact but was found to be empty of fuel. The right propeller was found in the feathered position, confirming the engine had stopped.
Evidence from the pilot's personal diary indicated that the right engine had experienced power loss two weeks prior to the accident. Furthermore, the investigation noted that the pilot's fuel drainage procedure was insufficient; he failed to drain enough fuel to ensure the presence of usable fuel beyond the 600ml residual amount. The investigation also highlighted that the pilot was facing significant financial hardship, which influenced his decision to proceed with the high-risk flight.
Findings
- Complacency and poor judgment: The pilot demonstrated a dangerous level of complacency by ignoring repeated engine malfunctions and failing to conduct a thorough inspection after the second engine failure during the takeoff roll.
- Inadequate fuel management: The pilot failed to verify the presence of usable fuel in the right tank, likely due to the high-pitch attitude during takeoff causing fuel to move to the rear of the tank, potentially introducing air into the lines.
- Operational risks: The flight was part of a mining operation involving an unregistered airstrip and an aircraft with overdue maintenance.
- Psychological factors: Financial distress motivated the pilot to accept extreme operational risks to ensure the completion of the flight.