What happened
On the night of June 5, 2001, an EMB-820C Navajo, registration PT-EHL, operated by Oliveira e Silva Táxi Aéreo Ltda, was performing a night flight from Franca, SP, to Congonhas, SP, transporting bank mail. During the approach to Congonhas, the pilot experienced a malfunction in the right engine and intentionally shut it down.
Despite the engine failure, the pilot did not declare an emergency to the control tower and proceeded to the traffic pattern for runway 35R. The aircraft approached the runway at an excessively high speed and high pitch angle, touching down on the final third of the runway. Due to the lack of remaining runway space to decelerate, the pilot attempted a go-around. Operating in a single-engine configuration, the aircraft lost lift, veered to the left, and stalled. The aircraft struck a residential building and caught fire, resulting in the death of the pilot and causing two minor injuries to people on the ground.
The investigation
CENIPA investigators examined the wreckage and the engines. The investigation established that the right engine had suffered a loss of oil pressure caused by the failure of the oil pump drive gear. Technical analysis revealed that the gear fracture was likely caused by fatigue, exacerbated by corrosion pits and excessive clearance within the pump mechanism. /nFurthermore, the investigation scrutinized maintenance records. It was found that the maintenance performed during the engine overhaul did not strictly adhere to Lycoming manufacturer requirements. Specifically, there was a lack of traceability for installed components and insufficient evidence that all gears had been inspected using non-destructive testing methods as recommended. The investigation also noted that the pilot's decision-making was influenced by a desire to complete the mission without the scrutiny that an emergency declaration would trigger.
Findings
- Maintenance failure: The failure of the oil pump drive gear was caused by fatigue and corrosion, which went undetected during the previous overhaul due to inadequate maintenance oversight and lack of component traceability.
- Pilot judgment: The pilot failed to declare an emergency to the tower, which prevented air traffic control from prioritizing the aircraft and preparing the airport's emergency services.
- Operational errors: The pilot conducted the final approach at speeds and pitch angles outside of the manufacturer's recommended parameters for single-engine operations.
- Decision making: The pilot's attempt to perform a go-around in a single-engine configuration, after landing too far down the runway, led to the loss of control and subsequent stall.