What happened
On July 20, 1999, a PA-23-250 operated by Scheffer do Ituxi Ind. e Com. S.A. was performing a transport flight from a private farm to the Aeroclube de Rondônia in Porto Velho, Brazil. The flight was intended to transport an ill passenger and an attendant. During a previous leg of the day, the right engine had already exhibited vibrations and a drop in fuel pressure; however, the pilot proceeded with the return flight.
While cruising at 5,500 feet, the right engine failed again, losing power and eventually stopping. The pilot attempted to maintain single-engine flight using the left engine but was unable to sustain the necessary altitude. As the aircraft descended to 800 feet, the pilot opted for a forced landing on highway BR 364. During the landing roll, the pilot had to maneuver to avoid an oncoming vehicle, causing the aircraft to veer off the road and into a roadside ditch. The aircraft sustained severe damage to the landing gear, propellers, wings, and flaps, but all three occupants remained uninjured.
The investigation
CENIPA investigators examined the aircraft's maintenance history and operational environment. The investigation noted that the aircraft had experienced long periods of inactivity and was often left exposed to environmental elements at the aeroclub, which could lead to the accumulation of debris or moisture in the fuel and oil systems. The pilot was found to be highly experienced with the type, but investigators noted evidence of excessive self-confidence and anxiety due to the mission requirements. Furthermore, the pilot did not consult the aircraft's checklist during the engine failure procedures and could not confirm the specific power settings applied to the remaining engine.
Findings
- Deficient judgment by the pilot, who decided to proceed with the return flight despite the engine issues encountered during the earlier leg of the day.
- Deficient planning, as the flight was conducted without adequate consideration of the known mechanical instability.
- Failure to follow procedures, specifically the omission of the aircraft checklist during the emergency.
- Environmental factors, including the aircraft being stored exposed to weather and long periods of inactivity, which may have contributed to fuel system contamination.
- Inadequate supervision by the aircraft owner regarding the operational readiness of the aircraft.