What happened
On July 13, 1999, an EMB-720 C, registration PT-RCS, was performing a visual flight from Pauiní to Rio Branco, Brazil, carrying a pilot and three passengers. During the final approach to Rio Branco, the aircraft entered a descending turn and performed a forced landing near a road in a low-vegetation area.
During the landing sequence, the aircraft's right wing struck a fence, and the plane continued for several meters before colliding laterally with a tree. The impact caused the aircraft to break in two. All four occupants (one pilot and three passengers) were uninjured, though the aircraft sustained severe damage.
The investigation
CENIPA's investigation established that the aircraft's fuel tanks were empty upon inspection following the accident. The investigation revealed that the pilot had departed Pauiní without refueling. During the flight, the fuel in one tank was exhausted, causing the engine to falter; the pilot switched to the remaining tank and continued toward Rio Branco. However, as the aircraft approached the airport, the second tank also ran dry, causing the engine to stop.
Investigators found that the aircraft lacked functioning fuel gauges, forcing the pilot to rely on manual checks, which were not performed prior to departure. Furthermore, the investigation highlighted a regional operational culture where pilots frequently reduced safety margins regarding fuel reserves to maximize payload and minimize costs, as refueling options in the region were limited to only two airports.
Findings
- Lack of situational awareness: The pilot failed to verify the actual fuel quantity before departure and did not request landing priority from Air Traffic Control despite the known fuel exhaustion in the first tank.
- Inadequate planning: The flight plan estimated a 3-hour endurance for a mission requiring 2 hours and 20 minutes, providing insufficient safety margins.
- Organizational culture: The operator's management style allowed pilots to make independent operational decisions without imposing safety regulations, and a local culture existed that tolerated flying with low fuel reserves.
- Deficient supervision: A previous occurrence involving the same aircraft landing with low fuel levels had not been addressed by the operator or authorities.
- Improper judgment: The pilot proceeded with the flight despite the inoperable fuel gauges and without confirming the remaining fuel volume.