What happened
On November 23, 2001, an EMB 820C, registration PT-RAZ, was performing an instrument flight from Bom Jesus da Lapa to Brasília. The flight proceeded normally until the aircraft was established on the final approach for runway 29 at Brasília International Airport. During the short final phase, the aircraft experienced a loss of power in the engines. The pilot attempted to restart the engines, but the effort was unsuccessful.
The aircraft drifted slightly to the right of the runway centerline and struck the ground approximately 61 meters before the threshold of runway 29. The impact caused severe damage to the airframe, particularly to the right wing, and the aircraft was subsequently declared a total loss. The pilot sustained serious injuries, and a passenger sustained serious injuries that ultimately led to their death 23 days after the accident.
The investigation
CENIPA investigators examined the wreckage and the engines to determine the cause of the power loss. Technical analysis of the engines revealed no internal component failures that would have caused the shutdown; instead, the evidence pointed to external factors. Testing of the fuel lines showed they were unobstructed, and significant fuel remained in the left wing tank at the time of the crash. However, the right engine's manifold pressure was near zero, while the left engine showed 8 inches of compression.
The investigation also looked into the aircraft's maintenance and operational history. While the aircraft's maintenance records were up to date, investigators found that the pilot had experienced several previous instances of single-engine flight with this same aircraft without reporting them to the operator. The investigation also noted that the fuel selector valve, which is difficult to access in an emergency, may not have been switched to the external tanks in time.
Findings
- Improper fuel management: The pilot likely failed to monitor fuel consumption or switch the fuel selectors to the external tanks, leading to the exhaustion of the internal tanks.
- Poor emergency decision-making: The pilot attempted to extend the glide by retracting the flaps during the short final, which increased the aircraft's sink rate and made the landing more difficult.
- Complacency and overconfidence: Having successfully managed previous single-engine situations without reporting them, the pilot may have been influenced by a sense of complacency and an overreliance on luck.
- Lack of operational oversight: The operator failed to supervise and investigate previous unreported engine failures, which prevented the implementation of corrective safety measures.