What happened
On February 23, 2004, an EMB-820C aircraft, registered as PT-EBU, was performing a return flight from Picos to Nossa Senhora de Fátima in the state of Piauí. The aircraft, operated by Bem-Te-Vi Táxi Aéreo Ltda., was being used for private transport. During the flight, while overflying the municipality of Monsenhor Gil, the aircraft suffered an engine failure.
Witnesses observed the aircraft flying at a low altitude, nearly striking a radio antenna. The crew attempted an emergency landing on a highway (BR-3/316), but the presence of vehicles prevented them from using the roadway. The pilots then diverted to a clearing near a eucalyptus grove. During the final approach, the aircraft struck a tree and impacted the ground in an inverted position. The impact caused significant damage to the cockpit, and a small fire broke out in the right engine, which was extinguished by local residents. Both pilots sustained fatal injuries.
The investigation
CENIPA's investigation established that the engine failure was caused by fuel exhaustion. Although the aircraft had been refueled prior to the mission, the crew had only filled the internal and external tanks, neglecting the nacelle tanks. Calculations showed that the mission required approximately 776 liters of fuel, but the available fuel in the partially filled tanks was only 689 liters.
The investigation also revealed that the crew had a history of disagreement regarding the fuel quantity; the pilot had ultimately yielded to the co-pilot's pressure to proceed despite the insufficient supply. Furthermore, the investigation found that the pilots were operating as "free-lance" individuals without formal employment ties to the operator, meaning they were not subject to the company's training or oversight programs. The investigation also noted that the pilots failed to follow emergency procedures, specifically the instruction to feather the propellers during the engine failure.
Findings
- Fuel Exhaustion: The primary cause of the engine failure was the insufficient amount of fuel on board to complete the planned mission.
- Poor Flight Planning: The crew failed to consult performance charts or consider historical fuel consumption rates when deciding not to refuel the nacelle tanks.
- Inadequate Oversight: The operator failed to exercise operational control or supervise the aircraft's activities, as the aircraft was not officially included in the company's operational specifications at the time.
- Crew Resource Management (CRM) Deficiencies: There was a breakdown in coordination, characterized by the co-pilot's authoritative decision-making and the pilot's lack of assertiveness in the face of unsafe operational pressures.
- Lack of Training: Due to their freelance status, the pilots had not undergone the company's required training programs, leading to limited knowledge of the aircraft's performance and emergency procedures.