What happened
On October 1, 1996, an Embraer EMB-810C aircraft, registration PT-RMP, departed from Pampulha Airport (SBBH) in Belo Horizonte, Brazil, for a test flight and subsequent transit to Carlos Prates (SNCH). Shortly after takeoff and the retraction of the landing gear, the right engine failed, causing the aircraft to yaw significantly.
In an attempt to manage the emergency, the pilot requested assistance from the passenger, who was also a qualified pilot, to perform single-engine emergency procedures. During this process, the passenger inadvertently switched off the magneto for the left engine, which had been functioning normally. This second failure left the aircraft without sufficient power to maintain flight at a low altitude. The pilot was forced to perform an emergency landing on a hillside, where the aircraft struck a tree, collided with a wall, and eventually came to a stop against an embankment. Both occupants sustained serious injuries.
The investigation
The CENIPA investigation examined the aircraft's maintenance history and the crew's actions. The investigation revealed that the aircraft had recently undergone maintenance at a facility not authorized to perform the specific adjustments and turbocharger installations required. Specifically, the workshop lacked the necessary pressure gauges for proper fuel pump regulation.
Investigators also reviewed the cockpit dynamics, noting that while the pilot was qualified, a pre-takeoff briefing regarding emergency procedures had not been conducted. Furthermore, the pilot had elected to take off from a runway intersection rather than using the full available runway length, a decision attributed to complacency during a routine ferry flight.
Findings
- Inadvertent Engine Shutdown: The primary cause of the loss of control was the passenger inadvertently shutting off the left engine's magneto while attempting to secure the failed right engine.
- Deficient Crew Resource Management: The pilot failed to establish a clear division of responsibility and did not conduct an emergency briefing, leading to the passenger's interference with the active engine.
- Improper Maintenance: The aircraft had undergone unauthorized maintenance procedures, including turbocharger installation and fuel pump adjustments, performed without proper instrumentation.
- Lack of Supervision: The aircraft owner failed to provide adequate oversight, allowing maintenance to be performed by a facility not certified for the required tasks.
- Operational Errors: The pilot's decision to depart from a runway intersection and the lack of a takeoff briefing contributed to the lack of preparedness for the engine failure.