What happened
On January 13, 2001, an EMB-721D Sertanejo, registration PT-RLQ, departed from the Flores Aerodrome (SWFN) in the state of Amazonas, bound for Borba. The aircraft was performing a passenger transport operation with a pilot and five occupants on board.
Shortly after takeoff, upon reaching an altitude of approximately 100 feet and after the landing gear had been retracted, the engine ceased operation. The pilot attempted to restart the engine by switching fuel tanks, but was unsuccessful. The pilot subsequently executed a forced landing approximately 100 meters from the runway threshold, colliding with a grove of buriti palms.
Following the impact, the aircraft caught fire. Although all occupants managed to evacuate the aircraft before the flames spread, the pilot and one passenger sustained minor injuries to the face. The aircraft sustained extensive damage and was destroyed by the fire.
The investigation
CENIPA investigators examined the engine components, including the fuel injector servo, electric pump, mechanical pump, and fuel distributor unit. The investigation revealed that the engine had undergone a major overhaul in November 2000 following a propeller strike.
Technical analysis of the fuel system identified significant internal issues. Investigators found corrosion on the fuel control unit's filter nut and the presence of foreign material within the combustion chamber. The mechanical fuel pump's equalization chamber diaphragm was ruptured, and the electric fuel pump was found to be malfunctioning due to debris—described as having characteristics of plastic mass—obstructing the internal vanes. Additionally, the fuel distributor unit was found to have an obstructed equalization orifice.
Findings
- Fuel System Failure: The engine lost power due to a cumulative failure of the fuel supply system, specifically the failure of the mechanical pump and the impaired performance of the electric booster pump.
- Maintenance Deficiencies: Although the engine had recently undergone a major overhaul, the presence of significant corrosion and foreign material suggests inadequate inspection or improper maintenance practices.
- Operational Non-compliance: The aircraft was registered under the Private Air Transport (TPP) category but was being operated for commercial air taxi (TPX) purposes, which was unauthorized.
- Lack of Safety Culture: There was evidence of poor organizational oversight, as previous engine vibrations and a prior in-flight engine failure had not been formally recorded in the aircraft logs.
- Pilot Judgment: The pilot proceeded with the flight despite being aware of previous engine irregularities and a lack of confidence in the maintenance quality.