final report a-597/cenipa/2016

FORMRFE 0517

COMANDO DA AERONÁUTICA

CENTRO DE INVESTIGAÇÃO E PREVENÇÃO DE ACIDENTES AERONÁUTICOS

FINAL REPORT

A-597/CENIPA/2016

OCCURRENCE: ACCIDENT

AIRCRAFT: PT-ENG

MODEL: EMB-820C NAVAJO

DATE: 06JUL2012

A-597/CENIPA/2016 PT-ENG 06JUL2012

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NOTICE

According to the Law nº 7565, dated 19 December 1986, the Aeronautical Accident

Investigation and Prevention System – SIPAER – is responsible for the planning, guidance,

coordination and execution of the activities of investigation and prevention of aeronautical

accidents.

The elaboration of this Final Report was conducted taking into account the contributing

factors and hypotheses raised. The report is, therefore, a technical document which reflects the

result obtained by SIPAER regarding the circumstances that contributed or may have contributed

to triggering this occurrence.

The document does not focus on quantifying the degree of contribution of the different

factors, including the individual, psychosocial or organizational variables that conditioned the

human performance and interacted to create a scenario favorable to the accident.

The exclusive objective of this work is to recommend the study and the adoption of

provisions of preventative nature, and the decision as to whether they should be applied belongs to

the President, Director, Chief or the one corresponding to the highest level in the hierarchy of the

organization to which they are being forwarded.

This Report does not resort to any proof production procedure for the determination of

civil or criminal liability, and is in accordance with Appendix 2, Annex 13 to the 1944 Chicago

Convention, which was incorporated in the Brazilian legal system by virtue of the Decree nº 21713,

dated 27 August 1946.

Thus, it is worth highlighting the importance of protecting the persons who provide

information regarding an aeronautical accident. The utilization of this report for punitive purposes

maculates the principle of “non-self-incrimination” derived from the “right to remain silent”

sheltered by the Federal Constitution.

Consequently, the use of this report for any purpose other than that of preventing future

accidents, may induce to erroneous interpretations and conclusions.

N.B.: This English version of the report has been written and published by the CENIPA with the

intention of making it easier to be read by English speaking people. Taking into account the

nuances of a foreign language, no matter how accurate this translation may be, readers are

advised that the original Portuguese version is the work of reference.


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SYNOPSIS

This is the Final Report of the 06JUL2012 accident with the EMB-820C NAVAJO aircraft, registration PT-ENG. It was classified as [Fuel] - “Fuel Related”.

During an aero survey flight, conducted at low altitude, the two aircraft engines shutdown.

The crew attempted to make a forced landing in a clearing, but during the approach, the aircraft collided against trees and was thrown toward the ground.

A fire got started immediately after the impact.

The aircraft was destroyed.

The pilot died, one crewmember had minor injuries and the other crewmember was unharmed.

An Accredited Representative of NTSB - National Transportation Safety Board – USA, (State where the aircraft was designed), was designated for participation in the investigation.


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CONTENTS

GLOSSARY OF TECHNICAL TERMS AND ABBREVIATIONS ........................................ 5

1. FACTUAL INFORMATION. .......................................................................................... 6

1.1 History of the flight. ........................................................................................................ 6

1.2 Injuries to persons.......................................................................................................... 6

1.3 Damage to the aircraft. .................................................................................................. 6

1.4 Other damage. ............................................................................................................... 6

1.5 Personnel information. ................................................................................................... 7

1.5.1 Crew’s flight experience. ........................................................................................... 7

1.5.2 Personnel training. .................................................................................................... 7

1.5.3 Category of licenses and validity of certificates. ....................................................... 7

1.5.4 Qualification and flight experience. ........................................................................... 7

1.5.5 Validity of medical certificate. .................................................................................... 7

1.6 Aircraft information. ........................................................................................................ 7

1.7 Meteorological information. ............................................................................................ 7

1.8 Aids to navigation........................................................................................................... 7

1.9 Communications. ........................................................................................................... 7

1.10 Aerodrome information. ............................................................................................... 8

1.11 Flight recorders. ........................................................................................................... 8

1.12 Wreckage and impact information................................................................................ 8

1.13 Medical and pathological information. ........................................................................ 10

1.13.1 Medical aspects. ................................................................................................... 10

1.13.2 Ergonomic information. ......................................................................................... 10

1.13.3 Psychological aspects. ......................................................................................... 10

1.14 Fire. ............................................................................................................................ 10

1.15 Survival aspects. ........................................................................................................ 10

1.16 Tests and research. ................................................................................................... 10

1.17 Organizational and management information. ........................................................... 11

1.18 Operational information. ............................................................................................. 11

1.19 Additional information. ............................................................................................... 12

1.20 Useful or effective investigation techniques. .............................................................. 13

2. ANALYSIS. ................................................................................................................. 13

3. CONCLUSIONS. ......................................................................................................... 14

3.1 Facts. ........................................................................................................................... 14

3.2 Contributing factors. ..................................................................................................... 15

4. SAFETY RECOMMENDATION. ................................................................................. 16

5. CORRECTIVE OR PREVENTATIVE ACTION ALREADY TAKEN…………....……...16


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GLOSSARY OF TECHNICAL TERMS AND ABBREVIATIONS

AGL

CA

Above Ground Level

Airworthiness Certificate

CG

CIV

Center of Gravity

Pilot’s Flight Logbook

CMA

MLTE

OEE

Aeronautical Medical Certificate

Airplane Multi Engine Land Rating

Special Equipment Operator

PCM Commercial Pilot License - Airplane

PPR

SAE-AL

SBQV

SNBR

Private Pilot License - Airplane

Aircraft Registration Category of Specialized Air Service – Aero Survey

ICAO location designator – Vitória da Conquista - BA

ICAO location designator – Barreiras Aerodrome - BA

SNGI

ICAO location designator – Guanambi Aerodrome - BA


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FACTUAL INFORMATION. 1.

Aircraft

Model: EMB-820C Operator:

Registration: PT-ENG Microsurvey Aerogeof. e Consultoria Científica Ltd. Manufacturer: EMBRAER

Occurrence

Date/time: 06JUL2012 - 1350 UTC Type(s):

Location: Rural Area “Fuel”

Lat. 14º43’33”S Long. 043º10’17”W Subtype(s):

Municipality – State: Espinosa, MG Fuel Related

1.1 History of the flight.

The aircraft took off from the Guanambi Aerodrome - BA (SNGI), with three crewmembers on board, in order to perform a low altitude aero survey flight, with a scheduled duration of two hours.

After about two hours of flight, the right engine presented irregular performance, stopping to work.

While the pilot was performing emergency procedures at low altitude, the left engine also stopped.

The commander attempted to land in a rural area, but the aircraft crashed into the vegetation of dry trees.

After the impact, the empennage was separated from the fuselage and the main tanks split.

The two crewmembers tried to remove the pilot from his station, unsuccessfully, and then evacuated the aircraft through the opening in the rear of the fuselage.

The aircraft caught fire and was destroyed.

The pilot died. One crewmember had minor injuries and the other one left unharmed.

1.2 Injuries to persons.

Injuries Crew Passengers Others

Fatal 1 - -

Serious - - -

Minor 1 - -

None 1 - -

1.3 Damage to the aircraft.

The empennage of the aircraft was separated from the fuselage, the main tanks were split and the fire caused the destruction of the aircraft.

1.4 Other damage.

Nil.


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1.5 Personnel information.

1.5.1 Crew’s flight experience.

Hours Flown

Pilot Crewmember

1

Crewmember 2

Total 3.876:00 510:00 83:05

Total in the last 30 days 83:00 83:00 83:00

Total in the last 24 hours 08:00 08:00 08:00

In this type of aircraft 238:00 175:00 83:00

In this type in the last 30 days 83:00 83:00 83:00

In this type in the last 24 hours 08:00 08:00 08:00

N.B.: The Data on flown hours were obtained from the Crewmembers’ Flight Logbooks records.

1.5.2 Personnel training.

The pilot took the Private Pilot course - Airplane (PPR) at Piauí Aeroclube, in 2002.

1.5.3 Category of licenses and validity of certificates.

The pilot had the Commercial Pilot License – Airplane (PCM) and had valid MLTE Rating.

Crewmember 1 had the OEE License and had valid Technical Qualification.

Crewmember 2 was under instruction to get the OEE License.

1.5.4 Qualification and flight experience.

The pilot and the crewmember 1 were qualified to perform the flight.

Crewmember 2 was under instruction to get the OEE License.

1.5.5 Validity of medical certificate.

All crewmembers had valid Aeronautical Medical Certificates (CMA).

1.6 Aircraft information.

The aircraft, serial number 820066, was manufactured by EMBRAER, in 1977 and was registered in the SAE-AL category.

The aircraft had valid Certificate of Airworthiness (CA).

The airframe, engine and propellers logbook records were updated.

The last inspection of the aircraft, the “50 hour-type” on 22JUN2012 was performed by a certified shop, in Goiânia - GO, having flown 239 hours and 10 min after the inspection.

The last overhaul of the aircraft, the "1000 hours type”, was performed on 13APR2012 by performed by a certified shop, in Goiânia - GO, having flown 271 hours and 30 min after the overhau.

1.7 Meteorological information.

The conditions were favorable for the visual flight.

1.8 Aids to navigation.

Nil.


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1.9 Communications.

The last contact established by the aircraft was through mobile telephony.

The pilot called the ground crew at SNGI, after about an hour and twenty minutes of flight, with the purpose of deciding whether they would go to Barreiras - BA (SNBR) or Vitória da Conquista - BA (SBQV) to fuel the aircraft.

1.10 Aerodrome information.

The occurrence took place outside the Aerodrome.

1.11 Flight recorders.

Neither required nor installed.

1.12 Wreckage and impact information.

During the approach to forced landing, the aircraft crashed into some dry trees.

With the impact, the tail separated from the fuselage, the main tanks broke apart and a fire started. The aircraft was destroyed.

Figure 1 - Higher concentration of the wreckage.

Figure 2 - Separated tail from the empennage after impact against trees.


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Figure 3 - Left engine and propeller.

Figure 4 - Right engine with flagged propeller.


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1.13 Medical and pathological information.

1.13.1 Medical aspects.

Not Investigated.

1.13.2 Ergonomic information.

Nil.

1.13.3 Psychological aspects.

Not Investigated

1.14 Fire.

After the impact, the main tanks were broken and a fire started, which destroyed the aircraft.

Figure 5 - Post-impact fire extension area.

Except for the tail, which separated after the first impact, the rest of the plane was destroyed by fire.

The fuel selectors were also destroyed, so it was not possible to determine their exact position at the time of the accident.

1.15 Survival aspects.

The aircraft was spotted by locals who saw the crash and headed for the impact site.

The two crewmembers tried to rescue the pilot but were unsuccessful, as he was unconscious and trapped.

The crew evacuated the plane through the opening at the back of the fuselage.

1.16 Tests and research.

The fuel, in this model of aircraft, was stored in four main tanks, two on each wing, and in two nacelle tanks, one in each engine housing.

The main tanks were made of flexible cells, installed two in each wing, denominated of internal tank and external tank. The external tanks had a capacity of 151 liters each, the


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internal tanks had a capacity of 212 liters each and the nacelle tanks had a capacity of 102 liters each.

In this way, the total fuel capacity of the aircraft was 930 liters, of which 893 liters were usable.

The internal and nacelle tanks of the engines were interconnected and could be supplied, by gravity, through the nozzle located in the inner tanks.

The aircraft was equipped with a fuel selector system that allowed the pilot to select the tank that would provide fuel for each engine. Each of the engines could receive fuel from the tanks installed on both wings, right and left.

For this, the system incorporated a cross-feed valve, designed to allow the right engine to run using fuel from the left wing tanks and vice versa (Figure 6).

Figure 6 - Representative illustration of the aircraft fuel panel.

According to the aircraft's manual, every flight hour of cruise, the tanks supplying fuel to the engines should be switched by the selector.

Damage to the right engine propellers was consistent with a flagged propeller situation (position corresponding to the maximum pitch of the propellers) and damage to the left engine propellers showed signals consistent with low power development or a transitional flagged condition.

Regarding the landing in case of engine failure, the aircraft manual contained the following note:

"Depending on the type of terrain, it may be more prudent to land with the landing

gear retracted".

1.17 Organizational and management information.

Nil.

1.18 Operational information.


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The aircraft was within the limits of weight and center of gravity (CG) specified by the manufacturer.

According to the planning, the take-off was performed on SNGI and the landing for refueling would be performed in another location, with subsequent return to the area of the aero survey.

It was the company's standard procedure to perform the aero survey flight to identify the presence of minerals in the ground, at a constant height of 500 feet above the ground (AGL), carrying specific equipment for the activity on board.

The operator always provided a mechanic to assist the crew in ground activities, such as fueling and inspecting the aircraft.

On the day of the occurrence, the aircraft was supplied with its maximum fuel capacity and would thus have more than five hours of endurance. The pre-flight inspection was performed and, according to reports, no discrepancies were found in the systems.

According to the company's operating standard, the take-off should be carried out with the fuel selectors positioned in "internal tanks".

The aircraft was then to rise to 2,500 ft., for testing the aero-survey equipment on board. After the test, the selectors would be positioned in external tanks and the height adjusted to 500 ft. AGL.

Also according to the aforementioned standard of operation, the fuel selectors should be changed from the "external tanks" position to "internal tanks" with about 50 minutes of flight, remaining in that position until their completion.

In addition, the fuel-rich mixing regime, power setting at 2,400 RPM and about 150 knots of speed should be used. The average fuel consumption for these operating standards was approximately 160 liters per hour.

According to reports, the take-off was carried out according to the standardization of the company, using the internal tanks feed. After the test of the on board equipment, the fuel supply of the external tanks was selected and realized descent to 330 ft.

Reports indicated that while flying the aircraft at low altitude, the pilot used the cell phone at various times, making calls or texting.

With about 1 hour and 20 minutes of flight, he called from the cell phone to the mechanic, who was on the ground in SNGI, in order to decide if the aircraft would continue to Barreiras - BA (SNBR) or Vitória da Conquista - BA (SBQV), in order to perform refueling.

During this contact, which was the last performed by the pilot, he did not report any abnormal behavior of the aircraft.

After approximately two hours of flight, the right engine showed a loss of power and irregular operation, stopping to operate afterwards.

One of the crewmembers stated that he questioned the pilot if he had changed the position of the fuel tank selectors and received no response. At that moment, according to the crewmember, the pilot seemed to show some disbelief as he tried to change the position of the fuel selectors.

Soon afterwards, still with the aircraft at low altitude, the left engine also stopped working. The pilot decided to make the landing in a clearing, after an area of high vegetation (dry trees).

The landing gear, which had been lowered, collided with the trees before the aircraft reached the chosen landing site.


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1.19 Additional information.

Nil.

1.20 Useful or effective investigation techniques.

Nil.

ANALYSIS. 2.

The aircraft carried out an aero survey flight, in the northern region of the state of Minas Gerais, with a scheduled duration of two hours. According to the planning, the take-off was performed on SNGI and the landing, for refueling, would take place in another location, with subsequent return to the area of the aero survey.

For the flight of the occurrence, the aircraft was supplied with its total capacity, which provided more than five hours of endurance. The pre-flight inspection was performed and no discrepancies were found in the aircraft systems.

Considering the average fuel consumption in the planned operation regime and the amount of fuel with which the aircraft was supplied, it is concluded that the external tanks (with 302 liters) would supply fuel to the engines for approximately one hour and fifty-three minutes of flight.

Therefore, changing the fuel selector from the external tanks to the internal tanks after 50 minutes of flight would be an adequate and safe measure, taking into account the risk of an engine shutdown due to lack of fuel supply.

According to one of the special equipment operators, the take-off was carried out according to the standardization, using the internal tanks feed and the modification of the fuel source for the external tanks was made at the end of the test of the equipment on board at 2,500 ft.

However, the pilot made a descent to 330 ft. AGL, instead of establishing the flight at 500 ft. AGL. In this way, it is possible that there has been a deviation from the operating rules of the operating company.

Also according to the special equipment operator, the pilot used the cell phone at various times of the flight, making calls and / or sending text messages, even at low altitude.

With about an hour and twenty minutes of flight, the pilot called from the cell phone to the mechanic who was in SNGI, in order to decide where the refueling would be carried out.

In this contact, which was the last performed by the crew, he did not report any abnormal behavior of the aircraft.

This communication, via telephone, could have been carried out by another crewmember on board, which would demonstrate a better use of the available human resources in the cabin.

In addition, the aircraft's fueling location could have been considered in the pre-flight planning prior to take-off.

Thus, the inadequate management of the tasks involved in planning and conducting the flight may have contributed to the pilot's forgetfulness to perform the alternation of fuel tanks.

One of the crewmembers reported that he had questioned the pilot about changing tanks at the fuel selector after stopping the engines, since he did not remember having seen him perform the procedure.


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According to the report, at that time, the pilot was trying to change the feed source in the fuel selector.

Thus, stopping the engines would not mean that there was no more fuel on board the aircraft. On the other hand, it is possible that the engines were no longer receiving fuel from the tanks, since the selectors were positioned for the external tanks.

Based on the time the aircraft used this power supply, it is likely that the fuel in these tanks has been completely consumed. This conjunction of factors may have culminated in stopping the engines.

The fuel selectors were destroyed by the action of the fire and it was not possible to determine their exact position. However, the characteristics observed in the engines, coupled with the presence of intense fire after impact, corroborate the theory that there was fuel on board at the time of the accident.

In this way, it is likely that the distraction caused by the use of the mobile device during the flight has contributed to the forgetfulness of effecting the exchange of the fuel tanks.

The decision to search for a cleared landing site after the failure of both engines at low altitude was compatible and appropriate for the situation faced.

However, the decision to lower the landing gear before reaching the chosen area compromised the performance of the aircraft in gliding flight. In addition, a landing with retracted landing gear could have been considered, since the chosen location was not prepared.

Finally, the descent to 330 ft. AGL and the establishment of level flight at that height may have characterized a deviation from the company's operational standards, since the standard defined by the company for that operation was an altitude of 500 ft. AGL.

CONCLUSIONS. 3.

3.1 Facts.

a) the crewmembers had valid Aeronautical Medical Certificates (CMA);

b) the pilot had valid MLTE Rating;

c) crewmember 1 had valid OEE’s Qualification;

d) crewmember 2 was under instruction to obtain OEE’s CHT;

e) the aircraft had valid Airworthiness Certificate (CA);

f) the aircraft was within the weight and balance parameters specified by the manufacturer;

g) the airframe, engines and propellers logbook records were updated;

h) the aircraft was supplied with its full capacity and had more than five hours of endurance;

i) the aircraft took off from SNGI to perform an aero survey flight with a scheduled duration of two hours;

j) according to reports, after the take-off and the test of the on board equipment, the pilot selected the fuel supply from the external tanks and commanded the descent to 330 ft.;

k) according to reports, the pilot used the cell phone while conducting the flight;

l) the pilot did not report any abnormal aircraft behavior during the flight;


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m) after about two hours of flight, the right engine presented irregular performance, stopping afterwards;

n) after stopping the right engine, the left engine also stopped;

o) the pilot decided to make a forced landing in a clearing, after a high vegetation area (dry trees);

p) before arriving at the place chosen for the landing, the aircraft collided with trees;

q) the tail of the aircraft was separated from the fuselage, the fuel tanks were split and a fire started;

r) due to the fire action, it was not possible to determine the position of the fuel selector during the accident;

s) the aircraft was destroyed; and

t) the pilot perished on the site, one of the crewmembers suffered minor injuries and the other crewmember left unharmed.

3.2 Contributing factors.

- Cabin Coordination – undetermined.

The possible use of the cell phone during the operation of the aircraft would characterize an inadequate management of the tasks related to the flight.

External communications, necessary for the coordination of the mission, could be carried out by other crewmembers on board, providing a better use of the human resources available for the operation of the aircraft.

It is possible that an improper division of duties among the crew contributed to the accident.

- Pilot’s forgetfulness – undetermined.

According to one of the crewmembers, the pilot performed activities not directly related to the conduct of the flight. Performing these other tasks may have impaired attention and situational awareness and provided distraction.

In this way, it is possible that the pilot has forgotten to carry out the expected procedures of alternating fuel tanks.

- Flight indiscipline – undetermined.

According to one of the crewmembers, the pilot conducted the flight to 330 ft. AGL, contrary to the limits recommended by the operating company that specified that he should maintain 500 ft. AGL.

It is possible that maintaining a lower altitude relative to the ground has influenced the time available for the pilot to manage the emergency situation and to perform the landing.

- Piloting judgment – undetermined.

Flying an aircraft at 500 ft. AGL requires crew attention. Although it was not possible to establish a direct cause and effect relation between this fact and the accident, the use of the mobile phone during the flight demonstrated an inadequate risk assessment inherent in that particular type of operation.

The decision to lower the landing gear before reaching the designated landing area compromised the aircraft's gliding performance. It may have contributed to the collision against the obstacles.


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In addition, according to the aircraft manual, landing without the landing gear should be taken into consideration, in some situations, depending on the type of terrain. Since the location chosen was not prepared for landing, nor was it known by the pilot, landing with collected landing gear would probably be more appropriate.

SAFETY RECOMMENDATION. 4.

A measure of preventative/corrective nature issued by a SIPAER Investigation Authority

or by a SIPAER-Link within respective area of jurisdiction, aimed at eliminating or mitigating

the risk brought about by either a latent condition or an active failure. It results from the

investigation of an aeronautical occurrence or from a preventative action, and shall never be

used for purposes of blame presumption or apportion of civil, criminal, or administrative liability.

In consonance with the Law n°7565/1986, recommendations are made solely for the

benefit of the air activity operational safety, and shall be treated as established in the NSCA 3-13

“Protocols for the Investigation of Civil Aviation Aeronautical Occurrences conducted by the

Brazilian State”.

Recommendations issued at the publication of this report:

To the Brazil’s National Civil Aviation Agency (ANAC):

A-597/CENIPA/2016 - 01 Issued on 12/04/2018

Act, together with the operator, to ensure that it adopts management mechanisms that provide due planning of legs, landings and departures, in accordance with the recommendations of the aircraft manuals and the legislation in force.

A-597/CENIPA/2016 - 02 Issued on 12/04/2018

Disclose to the Brazilian aeronautical community the importance of comply with flight procedures established by manufacturers, operators and educational institutions, as well as aspects related to the division of functions on board.

CORRECTIVE OR PREVENTATIVE ACTION ALREADY TAKEN. 5.

Nil.

On December 4th, 2018.

final report a-597/cenipa/2016

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