What happened
On February 22, 2001, at 19:35, an EMB 820C, registration PT-LFP, operated by Sete Táxi Aéreo Ltda, departed Varginha Airport (SBVG) for Belo Horizonte under IFR flight rules. The aircraft was performing a mail transport mission with a two-person crew.
Seconds after rotation, the right engine suffered a significant loss of power. The aircraft was unable to maintain flight and lost altitude, striking the terrain at the end of runway 22. The impact occurred in a level attitude with the landing gear and flaps retracted. Approximately 100 meters from the initial impact point, the aircraft came to a complete stop, and a fire broke out. The crew managed to evacuate the aircraft through a structural failure in the fuselage, as the cargo had shifted forward, obstructing the primary emergency exits. Both crew members sustained light injuries.
The investigation
CENIPA's investigation focused on the engine's performance, the aircraft's weight and balance, and the crew's cockpit management. Investigators found that the right engine had been operating within the 'yellow arc' for over a month, and the pilots had reported insufficient power on the previous day's flight.
Furthermore, the investigation revealed that the crew did not know the exact weight of the loaded cargo, as the operator did not provide specific weight documentation. The cargo, consisting of mail bags, was placed randomly on the cabin floor without proper restraint. There was also evidence that the aircraft may have departed outside of its weight and balance limits, as the pilot admitted to not verifying the load weight or consulting a weight and balance chart.
Findings
- Inadequate maintenance: The right engine had experienced persistent power issues that previous maintenance attempts, including turbocharger adjustments, failed to resolve.
- Failure in cockpit coordination: The pilot failed to communicate the engine failure to the co-pilot, instead simply requesting the retraction of the landing gear, which prevented joint decision-making.
- Improper cargo loading: The cargo was not properly secured, leading to its forward shift during deceleration, which blocked emergency exits and obstructed the cockpit.
- Lack of weight and balance oversight: The crew operated without knowledge of the actual cargo weight, contributing to an increased risk profile.
- Inadequate emergency procedures: There was no evidence that the pilot attempted to maintain the required single-engine climb speeds or properly manage the engine failure according to the aircraft manual.
Safety action
Following the investigation, several safety recommendations were issued:
- To the operator: Implement procedures to ensure pilots can verify cargo weight, ensure proper cargo restraint, and provide Crew Resource Management (CRM) training.
- To the local municipality: Maintain an active firefighting crew at Varginha Airport during all operational periods.
- To maintenance departments: Review maintenance programs to effectively detect and correct repetitive engine failures.