What happened
On June 15, 1995, an EMB-202 Ipanema, registration PT-UIM, departed from Fazenda São Paulo (SSFP) with the intention of proceeding to Rondonópolis (SWRD). During the flight, the pilot began flying at a low altitude to observe a sunflower plantation. During this maneuver, the engine failed and subsequently caught fire, signaled by the appearance of white smoke.
The pilot attempted an emergency forced landing on a small plateau. However, the aircraft failed to come to a complete stop within the available space, continuing to move until it reached the edge of a steep cliff. The aircraft fell into the precipice, resulting in its total destruction. The pilot managed to abandon the aircraft moments before the impact and sustained light injuries.
The investigation
CENIPA investigators initially faced difficulties accessing the wreckage due to the remote location. However, following a similar occurrence involving an aircraft of the same model and serial number six months later, the owner returned to the site. This secondary inspection revealed that the fuel metering unit's support and the mixture control cable had broken in an identical manner to the previous incident.
Further investigation into the aircraft's records revealed that a scheduled maintenance inspection had been omitted by the operator. Additionally, the investigation noted that the pilot, who was also the operator, lacked administrative or technical oversight, which allowed for deviations from flight rules, such as the low-altitude maneuvering that restricted landing options.
Findings
- Mechanical failure: The engine failure and subsequent fire were caused by the breakage of the fuel metering unit support and the mixture control cable.
- Maintenance deficiency: The aircraft was operating with an overdue scheduled inspection, indicating a failure in the operator's maintenance program.
- Operational errors: The pilot's decision to fly at low altitude to observe crops significantly reduced the time available to respond to the engine failure and limited the selection of a suitable landing site.
- Inadequate landing area: The chosen plateau was too small to safely stop the aircraft, leading to the overrun into the cliff.
- Lack of oversight: The absence of supervisory measures allowed for flight rule non-compliance and improper flight planning.