South America

Loss of control of the airplane in flight, during a left turn, due to the failure of the right engine (n°2) during takeoff, caused by a fuel exhaustion.
The following contributing factors were identified:
- Failure of the pilot to comply with the pre takeoff checklist,
- Failure of the pilot to check the fuel selector switch and the fuel quantity prior to start the engines,
- Failure of the pilot to feather the propeller of the right engine (n°2) during an emergency situation,
- Failure of the pilot to bring the flaps to the neutral position during an emergency situation,
- Decrease of the speed and altitude of the airplane,
- Increase bank of the wing during a left turn.

The investigation determined that the accident was caused by the following probable causes:
- Loss of control in-flight as a consequence of the decrease in minimum in-flight control speed and drag generated by the impossibility of performing the No. 1 engine propeller feathering in the face of engine failure.
- Malfunction of the lubrication system of engine No. 1, evident in the abundant oil leakage from the engine, in flight, and in the governor of the left propeller; although discrepancies were found in the maintenance of the propeller feathering pressure line, it was not possible to determine the origin of the oil leakage.
- Weaknesses in the aircraft Operator's operational procedures, lacking a standard that would facilitate a crew's decision making to act in the event of critical failures, in matters such as making an emergency landing on unprepared field or the selection of an alternate airfield.

Contributing Factors:
- Deficiencies in standard maintenance practices during repairs performed on the No. 1 engine's propeller propeller feathering oil pressure line.
- Non-compliance with an effective and reliable maintenance program, which did not verify the operating conditions of the aircraft components; it was not possible to determine compliance with the last 50-hour service, Phase A, to engine No. 1 according to the company's maintenance program, since there are no records of that service in the Flight Log.
- Inefficient safety management system of the Operator for not detecting errors in the maintenance processes and in the conduct and control of operations.

Conclusions regarding factors related to the accident:
- At the time of the event, meteorological conditions were poor with a strong storm, rain and gusts of wind.
- Visual cues may have been reduced due to heavy rain falls.
- The aircraft was displaced from the runway center line when it made contact with the ground.
- The aircraft made contact with the left landing gear off the runway due to strong gusts of wind.
- The lateral excursion to the grassy area occurred due to the impossibility of recovering the trajectory of the aircraft, once it was displaced by the action of the wind.

The following findings were identified:
- Attention,
- Judgment,
- Perception,
- Management planning,
- Decision making processes,
- Organization processes,
- Support systems.

The flight was undertaken with an airplane whose center of gravity was beyond the rear center of gravity limits and a mass greater than the maximum take-off mass. The load was not secured. As a result, the performance of the aircraft was degraded and piloting made more difficult. The BEA investigation did not reveal any major failure that could explain a loss of power. Engine performance may have been lower than the manufacturer's standards, due in particular to improper adjustment of the mechanical fuel pump, probably resulting from unsuitable maintenance. This defect was most likely already present on previous flights. It is likely that the power required for the initial climb was greater than what the engine could deliver. This brought the aircraft into a situation where the speed gradually decreased. When the pilot turned, the stall warning sounded and the pilot sensed the engine was losing power.