What happened
On June 23, 2001, an EMB 810 D SENECA III, registration PT-RUM, was performing a flight from Sorocaba to São Paulo (Congonhas). The aircraft was operated by Zaki Aerotáxi Ltda and carried a pilot and one passenger.
Upon arrival at Congonhas, the pilot attempted two ILS approaches for runway 17R but was unable to establish visual contact with the runway due to low ceilings and fog. The pilot subsequently diverted to the alternative airport, Guarulhos (SBGR). During the approach to Guarulhos, the pilot requested an expedited arrival due to low fuel levels. While maneuvering for the approach to runway 09, the right engine failed due to fuel exhaustion.
As the pilot attempted to maintain control in a single-engine configuration, the aircraft's airspeed dropped to 55 knots, which was below the minimum controllable airspeed (VMC) of 62 knots. The aircraft lost control and struck trees and a residence approximately 3.2 NM from the runway threshold. Both occupants sustained fatal injuries.
The investigation
CENIPA's investigation focused on the sequence of events leading to the engine failure and the loss of control. Investigators examined the aircraft's maintenance records, which showed that a 50-hour inspection had been performed only one hour prior to the accident. The investigation also reviewed the pilot's flight experience, noting that while qualified for IFR and multi-engine operations, the pilot had limited experience in instrument flight operations.
Technical examinations of the avionics revealed that the aircraft's glide slope indicator had been malfunctioning for approximately one month, and no repairs had been documented. Additionally, investigators found that the pilot had incorrectly set the altimeter to 1019.5 mb instead of the required 1023 mb, resulting in the aircraft being approximately 110 feet higher than intended during the approach.
Findings
- Fuel Exhaustion: The right engine failed because the aircraft ran out of fuel during the diversion to the alternative airport.
- Adverse Weather: Low visibility and low ceilings at both Congonhas and Guarulhos hindered the pilot's ability to maintain visual contact and manage the emergency.
- Loss of Control: The pilot failed to maintain sufficient airspeed during single-engine flight, allowing the aircraft to drop below VMC.
- Inadequate Planning: The pilot failed to verify updated meteorological conditions at the destination and alternative airports prior to departure.
- Maintenance Deficiencies: A known malfunction in the glide slope indicator had not been repaired, and the pilot's incorrect altimeter setting contributed to an unstable approach.
- Judgment and Experience: The pilot's decision to proceed with the flight despite deteriorating conditions and the lack of an early emergency declaration contributed to the outcome.