What happened
On July 17, 2000, a Beechcraft C-90, registration PT-LQS, was performing the final leg of a multi-stage flight from Brotas to São Paulo when it suffered a dual engine flameout. The aircraft was operating under IFR conditions and had been completing several flight segments throughout the previous two days. As the aircraft approached the Diadema waypoint within the São Paulo Terminal Control Area (TMA), both engines failed due to fuel exhaustion.
With no engine power remaining, the crew initiated a glide toward the ground. The pilot attempted a forced landing on the Rodovia dos Imigrantes highway. During the approach, the aircraft encountered several sets of overhead power lines, necessitating a steep maneuver that left the aircraft nearly stalled. The aircraft struck the roadway violently before colliding with a concrete guardrail. The impact caused the collapse of the landing gear and severe structural damage to the fuselage, rendering the aircraft a total loss. All five occupants—two crew members and three passengers—were able to evacuate the aircraft unharmed.
The investigation
CENIPA's investigation focused on the fuel management practices and the operational environment of the operator. Investigators found that while the aircraft's maintenance records were up to date, the pilot utilized a non-standard method for tracking fuel, relying on manual subtractions from an initial total rather than utilizing onboard gauges. Notably, the right fuel quantity indicator was inoperable, though it was unclear if this was due to the impact or a pre-existing issue.
The investigation also revealed significant organizational failures within the company. The pilot had failed to properly account for the fuel consumed during previous flight segments, leading to a flight plan that significantly overestimated remaining endurance. Furthermore, the investigation identified a lack of Crew Resource Management (CRM) training and a breakdown in cockpit coordination, exacerbated by a difficult interpersonal relationship between the pilot and co-pilot. The company's management was also found to have been aware of various operational irregularities, including the use of a TPP-category aircraft for charter flights, yet failed to implement corrective actions.