What happened
On May 2, 2000, a PA 28-235, registration PT-JKZ, was performing a ferry flight from Arapoti to Ponta Grossa, Brazil. During the takeoff roll, the aircraft reached rotation speed when the engine suddenly failed. The pilot attempted to land on the remaining portion of the runway, touching down approximately 100 meters from the end. However, the aircraft overran the runway, descended a bank, and collided with a pile of wooden logs located about 20 meters past the runway threshold. The impact caused the right wing to be torn off and resulted in two minor injuries (one pilot and one passenger). The aircraft sustained severe damage.
The investigation
The CENIPA investigation focused on the cause of the engine failure and the maintenance standards of the aircraft. Technical examinations of the Lycoming 0-540-0-B4B5 engine, conducted by the Institute of Aeronautics and Space, ruled out internal mechanical failures such as lubrication issues or malfunctions in the magnetos or carburetor. However, investigators found several maintenance non-conformities, including the use of an automotive alternator, electrical tape on alternator cables, and the use of epoxy for sealing. While these issues were deemed insufficient to cause the engine to stop, they indicated a poor quality of maintenance services.
Investigators also examined the possibility of water contamination in the fuel. Although the pilot reported draining the tanks, the lack of fuel samples collected during the initial response made it impossible to confirm. The investigation noted that the aircraft had been left unattended overnight at the Arapoti aerodrome, which lacked security, and that the company was facing financial difficulties and threats of sabotage from former employees.
Findings
- The engine failure was likely caused by external factors, such as the presence of water in the fuel, which could not be definitively proven due to the lack of fuel samples.
- The maintenance performed on the aircraft was periodic but inadequate, characterized by poor workmanship and improper repairs.
- The pilot's psychological motivation to fly, despite being aware of the aircraft's maintenance discrepancies, contributed to a culture where flight safety was secondary to operational desires.
- Deficiencies in flight planning and supervision were noted, as the pilot did not sufficiently verify the effectiveness of the fuel tank drainage.
- The lack of security at the aerodrome and the absence of fuel tank cap locks increased the risk of unauthorized interference or contamination.