Crash: Manaus Aerotaxi E110 near Manaus on Feb 7th 2009, engine failure

30.07.2010 - 15:25

Brazil s Centro de Investigacao e Prevencao de Acidentes Aeronauticos (CENIPA, center for investigation and prevention of aviation accidents) released their final report in Portugese concluding following facts: a) The charter flight from Coari to Manaus took off at 12:40L b) The takeoff weight was 6414kg (14128lbs) c) At 13:15 the airplane contacted the Amazonic Area Control Center (ACC-AZ) reporting to be at FL115 and beginning the descent d) The pilot reported 20 people on board of the aircraft to ACC-AZ when in reality there were 28 people on board e) The pilot reported to Approach Control Manaus (APP-MN) they would return to Coari but continue to descend via a slight right exit route towards the runway of Manacapuru f) The aircraft impacted the river 39.5nm west of Manaus and submerged soon after g) 22 passengers and 2 crew died, 4 passengers were rescued with minor injuries h) The aircraft was enroute when the left hand propeller stopped spinning about 30 minutes into the flight i) The weight of the aircraft at the time of the accident was estimated at 6219 kg (13700 lbs) j) Tests revealed the left hand engine developed no power k) The right hand engine showed evidence of operability l) The electronics of the left hand main electrical fuel pump was found burned, it could not be determined whether the damage occurred in flight or post impact m) The fuel pump never ran dry demonstrating the existance of fuel in the left wing fuel tank before impact with water n) A discrepancy was identified in the starter controller that could have caused a slower than normal engine start up soaking the plugs and causing a failure of startup o) The left hand mechanical fuel pump produced a lower output pressure than expected due to erosion in the fuel outflow area p) The heating element of the left hand "Oil Fuel Heater" was stuck in the open position q) All switches of the electrical fuel pumps were in the position "connected" r) There was a layer of low cloud near the runway of Manacapuru s) The aircraft, already near the threshold of runway 08, drifted off to the left and impacted the water t) The aircraft impacted water with a 30 degrees left hand bank angle (left wing impacting water first), subsequently the nose struck the water u) There was no preparation of the passengers for emergency procedures preceding the flight or inflight during preparation for the emergency landing CENIPA lists a number of extensive contributing factors, most notably: - Despite the experience of the captain he had little training for abnormal procedures - Preflight checks were likely left to the first officer (usual in the company) - The crew allowed an overweight takeoff and did not brief the passengers - Had the operator s maintenance checked the fuel oil heater temperature, they would have detected the failure of the heater element and replaced the oil fuel heater - The pilot did not apply the correct handling technique for single engine operation in accordance with the operating manual - Permitting an overweight takeoff did not take into consideration performance in case of an engine failure - Due to the overweight continued flight after the engine failure was impossible - It is possible that the failure of the fuel heating element was caused by a deficiency in the material used, that was possibly caused by the manufacturing process The captain had 18870 flying hours of experience thereof 7795 on type, the first officer 1011 hours thereof 635 on type. Detail Map (Graphics: AVH/Google Earth): Read the article at http://avherald.com/h?articleA4adbb8/0003 Modify your subscription at http://avherald.com/h?login