What happened
On April 1, 2004, a Cessna 150J, registration PT-KYB, was conducting a primary flight training mission from Campo de Marte Aerodrome (SBMT) to Jundiaí and back. The crew consisted of an instructor and a student pilot. Approximately 40 minutes into the flight, while on the long final approach to Campo de Marte, the engine experienced an instantaneous failure and ceased functioning.
In response to the engine loss, the instructor took control and executed a left turn to attempt an emergency landing on a paved avenue. During the low-speed maneuver, the right wingtip struck a public light pole, causing the aircraft to pivot 180 degrees. The aircraft then struck the ground and the left wing collided with a metal door of a warehouse. Despite the severe damage to the aircraft, both the instructor and the student emerged uninjured.
The investigation
CENIPA investigators examined the engine, fuel system, and aircraft maintenance records. Post-accident testing of the engine on a test bench showed it functioned normally, and the fuel system was found to be intact and free of obstructions. The fuel tanks were also verified to have the correct unuseable fuel limits.
However, the investigation revealed significant discrepancies in the aircraft's logbooks. The flight hour records were inaccurate, with the total hours recorded in the flight report being approximately 40 hours less than what was actually shown on the aircraft's odometer. Furthermore, the maintenance logs for the airframe, engine, and propeller were outdated, and the flight diary lacked proper entries regarding previous mechanical discrepancies.
Findings
- Inadequate fuel planning: The flight was not planned in accordance with required safety standards for VFR operations, specifically regarding minimum fuel reserves.
- Inaccurate fuel estimation: During pre-flight, the crew relied on unreliable estimation methods, such as calculating endurance based on previous flights rather than performing a physical dipstick check.
- Fuel exhaustion: The aircraft had been refueled with only 20 liters for the final leg. Based on an average consumption of 30 liters per hour and the aircraft's unuseable fuel characteristics, the engine failed due to fuel exhaustion after 40 minutes of flight.
- Lack of oversight: The flight school failed to establish proper guidelines for flight planning and did not maintain adequate supervision over aircraft documentation and logbook accuracy.