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| Date: | Monday 16 September 2019 |
| Time: | c. 20:35 UTC |
| Type: |  ATR 72-202 |
| Owner/operator: | MAP Linhas Aéreas |
| Registration: | PR-MPY |
| MSN: | 519 |
| Year of manufacture: | 1998 |
| Engine model: | P&W Canada PW124B |
| Fatalities: | Fatalities: 0 / Occupants: 43 |
| Other fatalities: | 0 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Itaituba Airport, PA (ITB/SBIH) -
 Brazil
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | Itaituba Airport, PA (ITB/SBIH) |
| Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Having been accommodated in a hotel in Belem overnight, both pilots reported for duty at Belem airport in mid-morning. They were to operate scheduled passenger flights from Belem to Manaus and back to Belem with intermediate stops in both directions at Altamira and Itaituba. Sufficient fuel was loaded for the Belem-to-Altamira sector, and the flight was completed without event. Once there, having received the flight despatch document prescribing the minimum fuel required for the next sector, the captain arranged for and supervised the uplift of what he believed would be sufficient fuel to reach Manaus without further refuelling at Itaituba. He was aware that although fuel was available at Itaituba if required, there were no ground personnel there to support any requested refuelling.
Once on the ground at Itaituba, it was found that the fuel used for the Altamira-Itaituba sector had been 20% greater than expected - 778kg instead of the forecast 644kg which left a recorded 2,022 kg in tanks. The flight despatch document for the Itaituba departure, which the captain was presented with and signed, showed a minimum fuel required of 2,116 kg but no fuel uplift occurred. It was not possible to determine whether the pilots had “not noticed or disregarded the difference between the prescribed minimum departure fuel and the indicated fuel on board”.
The flight departed for Manaus but whilst en route, Air Traffic Control (ATC) advised that Manaus had been closed because of an aircraft accident with no estimate of when it might reopen. The captain initially instructed the first officer to reduce speed and remain at FL180, but a few minutes later, when icing conditions were suspected, a descent to FL160 was made. When the lack of information on any reopening of Manaus continued, the decision was made to divert. Fuel remaining shown on the fuel quantity indicating system (FQIS) indicated that sufficient fuel was available to divert to the designated alternate, Tefé. But the captain considered that returning to Itaituba might be a better option since it was not only slightly nearer (253 nm instead of 281nm) but the weather conditions were known to the crew. Proceeding to Tefé would mean continuing westwards beyond Manaus, and after contacting company operations, this was approved. After 25 minutes holding, the diversion was commenced by climbing to FL190.
The pilots’ recollection was that the CAP FUEL caution, which is activated when the fuel remaining in a main (wing) fuel tank according to the FQIS is less than 160 kg and a low fuel light is illuminated, was present for “some time” during the flight back to Itaituba before going out. However, recorded data showed that this had actually occurred whilst in a turn during the Manaus hold at FL 160. The same data source also showed that three other brief CAP FUEL activations had then occurred whilst the flight was still level at FL190 during the return to Itaituba. The first two occurred within six minutes of each other midway between Manaus and Itaituba at FL190, and the third ten minutes later with 85nm to go.
Twenty-one minutes later, when only 3.3 nm from Itaituba, a fifth CAP FUEL activation occurred as the left engine power dropped, and 15 seconds later, this engine failed at a recorded 1,446 feet agl. The first officer continued visual positioning via left base to final for runway 05, and a single engine touchdown was completed without further event. As the speed on the landing roll decreased through 70 knots, the captain took control to prepare for the 180° turn and backtrack necessary to clear the runway. Whilst this was occurring, the right engine also ran down. A restart attempt of this engine was successful and enabled the captain to complete the taxi to the allocated parking position where the engine was shut down and the passengers disembarked. The pilots stated that only when the successful restart of the right engine had occurred did the right side ‘LO LVL’ light on the FQIS illuminate. The (external) magnetic fuel level indicators (MFLIs) were used to check the actual useable fuel in tanks, and this was found to be zero in both cases despite the FQIS indication that 410 kg remained.
Contributing factors
Attention – undetermined.
Due to the multiple tasks performed by the pilots while on the ground in SBIH, there was possibly a reduction in their process of attention, which may have caused lapses related to automatic processes, and distractions concerning the amount of fuel required for starting operations in SBIH, since the PIC signed the flight dispatch, which contained the minimum fuel requirements.
Crew Resource Management – a contributor.
There was inefficiency in the utilization of the human resources available for the operation of the aircraft, due to an inappropriate management of the tasks assigned to each pilot, considering their inobservance of the minimum fuel required for starting operations in SBIH.
Aircraft maintenance – a contributor.
After the occurrence of the serious incident, and upon completion of the aircraft repair work, the fuel quantity indicator of the PR-MPY resumed proper operation anew, evidencing that the FQI components had problems that interfered directly with the fuel system indication. Thus, one verified the non-conformity of the maintenance services previously performed on the aircraft, independently of having been preventive or corrective, since the PR-MPY had remained with a system failure that contributed to the serious incident.
Support personnel – undetermined.
The fact that there was no support staff at SBIH to perform post-flight, pre-flight and refueling tasks may have strongly increased the pilots’ workload, which may have resulted in possible distraction as to the need of refueling the aircraft.
Organizational processes – undetermined.
One cannot rule out the possible contribution of the company's organizational support, since, despite the fact that MAP Linhas Aéreas Ltda. possessed its own team of mechanics, it was actually Manaus Aerotáxi the company responsible for the maintenance of the aircraft, since MAP Linhas Aéreas Ltda did not have certification for the provision of maintenance services. Such state of circumstances may have led to failures in the supervision or, even, in the design of organizational processes important for the preservation of safety.
Managerial oversight – a contributor.
In view of the various non-conformities observed in the components of the fuel indication system after the occurrence, one inferred that there were failures in the monitoring and oversight of the maintenance services of the operating company.
Accident investigation:
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Sources:
https://skybrary.aero/sites/default/files/bookshelf/35077.pdf
https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-grave-de-latr72-immatricule-pr-mpy-exploite-par-tap-survenu-le-16092019-a-itaituba-enqu/
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 27-Sep-2019 17:32 | harro | Added |
| 27-Sep-2019 17:35 | harro | Updated [Aircraft type, Registration, Operator, Total occupants, Other fatalities, Country, Nature, Departure airport, Destination airport, Narrative, ] |
| 16-Aug-2025 22:19 | Justanormalperson | Updated [Time, Location, Source, Narrative, ] |
| 16-Aug-2025 22:20 | Justanormalperson | Updated |
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