What happened
On March 21, 1999, an AB-180 RVR, registration PP-GAL, departed from the Pindamonhangaba Aerodrome (SDPD) bound for Guaratinguetá (SBGW). The flight was operated by Aeroclube de Guaratinguetá with one pilot and one passenger on board.
Immediately following takeoff, the pilot initiated a left turn and established a high pitch angle. As the pilot reduced power to cruise settings at approximately 300 to 350 feet, the engine suffered a sudden loss of power and ceased operation. The pilot attempted to restart the engine in flight by engaging the starter twice, but these attempts were unsuccessful.
Unable to return to the runway, the pilot attempted an emergency landing in a nearby field. During the approach, the aircraft's left landing gear struck a fence post at an angle of 30 to 40 degrees, causing the aircraft to strike the ground and roll over before coming to a stop in a marshy area. The pilot sustained minor injuries, while the passenger was uninjured.
The investigation
CENIPA investigators examined the engine components, including the carburetor and magnetos, but found no mechanical failures that would have caused the engine to stop. However, investigators noted that the starter motor's drive gear was jammed against the ring gear, suggesting the starter may have been engaged while the propeller was already in motion.
Regarding the fuel supply, the investigation noted that refueling at the Pindamonhangera Aeroclube was performed using canisters, and discrepancies in fuel storage and quality control standards were identified at that location. While water contamination was a hypothesis, the pilot had drained the tanks prior to takeoff without finding any abnormalities.
The investigation also focused on the pilot's emergency management. The aircraft was found with the flaps in the retracted position, which contradicted the flight manual's emergency procedures for engine failure. Furthermore, the pilot failed to complete several critical shutdown steps, such as turning off the master switch and magnetos, tasks that were eventually performed by first responders.
Findings
- Fuel starvation due to aerodynamic effects during the high-pitch takeoff maneuver was considered the most probable cause of the engine failure.
- Deficient instruction and training, evidenced by the pilot's failure to follow established emergency procedures and incorrect aircraft configuration (flaps) during the emergency landing.
- Improper emergency management, including the likely attempt to engage the starter while the engine was rotating, which caused mechanical interference in the starter assembly.
- Inadequate fuel storage standards at the Pindemanhangaba Aeroclube, which presented a potential risk of contamination.