What happened
On a flight from Juará to Cuituba, the PT-GJH, a single-engine aircraft, experienced a critical engine failure during its final approach to the runway. The pilot reported a loss of power in the left engine and requested an emergency landing at the nearest available airstrip. Approximately four minutes after the initial failure, the aircraft struck trees with its left wing before impacting the ground at a steep 40-degree dive angle. The impact and subsequent fire resulted in the complete destruction of the aircraft and the deaths of one person, the pilot.
The investigation
The CENIPA investigation revealed a systemic failure in both maintenance and operational oversight. Investigators found that the aircraft's maintenance program was significantly overdue, having exceeded its scheduled inspection interval by several hours. Furthermore, the investigation uncovered that the company's maintenance base in Cuiabá lacked essential supplies, including proper cleaning materials, spare parts, and even basic consumables like water and oil.
Technically, the investigation established that the left engine failed because the fuel injectors were completely obstructed. This was linked to a failure in the maintenance routine, as the injectors had not been cleaned during recent inspections. Additionally, a fatigue-induced failure of a turbine blade in the gas generator was identified, which caused significant vibration and contributed to the loss of power.
Findings
- Maintenance Neglect: The aircraft was operating beyond its scheduled inspection limits, and critical components, such as fuel injector nozzles, had not been properly serviced.
- Operational Deficiencies: The operator failed to implement proper weight and balance calculations for each takeoff and failed to specify cargo destinations, compromising flight safety.
- Inadequate Training: The crew's emergency response was hindered by insufficient training in emergency procedures, particularly as the commander had only recently transitioned into the role.
- Inadequate Infrastructure: The maintenance facility lacked the necessary logistics and supplies to ensure the airworthiness of the fleet.
- Environmental Factors: A strong 70-knot wind during the approach contributed to the aircraft's unstable flight path, making recovery impossible after the engine failure.