Crash of a Learjet 35A in Río Grande: 4 killed

Date & Time: Jul 1, 2022 at 1410 LT
Type of aircraft:
Operator:
Registration:
LV-BPA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Río Grande – San Fernando
MSN:
35-143
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
9338
Captain / Total hours on type:
2122.00
Copilot / Total flying hours:
6913
Copilot / Total hours on type:
717
Aircraft flight hours:
13917
Aircraft flight cycles:
13170
Circumstances:
The airplane was returning to its base in San Fernando following an ambulance flight from Comodoro Rivadavia to Río Grande. Shortly after takeoff from Río Grande-Gobernador Ramón Trejo Noel Airport Runway 26, while in initial climb, the airplane rolled to the left, stabilized momentarily then rolled again to the left, lost lift and crashed in a huge explosion 1,870 metres pas the runway end and 300 metres to its left. The airplane was destroyed by impact forces and a post crash fire and all four occupants were killed.
Crew:
Claudio Canelo, pilot,
Héctor Vittore, copilot.
Passengers:
Diego Ciolfi, doctor,
Denise Torres Garcá, nurse.
Probable cause:
During the climb, immediately after takeoff, the aircraft rolled to the left, stabilized momentarily, and then rolled again to the same side. The second roll caused excessive bank, resulting in localized lift loss on the left wing, which led to a loss of altitude until impact with the ground. Information obtained during the investigation suggests that the aileron interconnection cable was disconnected at the time of the accident. Disconnection of the aileron interconnection cable causes a loss of synchronization between the left (pilot) and right (copilot) controls, allowing only right turns from the left control and left turns from the right control. This disconnection likely generated asymmetrical responses in the control inputs, making it difficult to control the aircraft and contributing to the loss of control. Cockpit conversations suggest that the copilot, seated on the right, began the takeoff run and, after the second left bank, transferred control to the pilot, seated on the left. At low altitude, the attempt to correct the left wing tilt, once in a stall situation, proved ineffective. According to the aircraft's maintenance records, the last replacement of the aileron interconnection cable was performed at 13,217.5 total flight hours July 18, 2016. The procedure for replacing the aileron interconnection cable did not clearly establish the removal and installation of the locking clips. The procedure for checking the tension of the aileron system cables, carried out on February 28, 2020, at 13,695.7 flight hours, did not clearly establish the installation of the locking clips. It is reasonable to conclude that the cable became disconnected due to the absence of the locking clips, which would have allowed the tensioner to gradually unscrew under the dynamic loads resulting from successive flights. The conclusion that the cable detachment was due to the absence of the locking clip suggests shortcomings in the training of the personnel responsible for inspecting the aircraft, as well as in the supervision of maintenance tasks by the maintenance manager. No evidence of failure of other flight control components that could have contributed to the accident was found.
Final Report:

Crash of a Learjet 35A in Santee: 4 killed

Date & Time: Dec 27, 2021 at 1914 LT
Type of aircraft:
Operator:
Registration:
N880Z
Flight Type:
Survivors:
No
Site:
Schedule:
Santa Ana - Santee
MSN:
35A-591
YOM:
1985
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2200
Copilot / Total flying hours:
1244
Aircraft flight hours:
13582
Circumstances:
Earlier on the day of the accident, the flight crew had conducted a patient transfer from a remote airport to another nearby airport. Following the patient transfer, the flight crew departed under night conditions to return to their home base. Review of air traffic control (ATC) communication, as well as cockpit voice recorder (CVR) recordings, showed that the flight crew initially was cleared on the RNAV (GPS) runway 17 instrument approach. The approach plate for the instrument approach stated that circling to runway 27R and 35 was not authorized at night. Following the approach clearance, the flight crew discussed their intent to cancel the approach and circle to land on runway 27R. Additionally, the flight crew discussed with each other if they could see the runway. Once the flight crew established visual contact with the runway, they requested to squawk VFR, then the controller cleared them to land on runway 17. The flight crew then requested to land on runway 27. The controller asked the pilot if they wanted to cancel their instrument flight rules (IFR) flight plan, to which the pilot replied, “yes sir.” The controller acknowledged that the IFR cancellation was received and instructed the pilot to overfly the field and enter left traffic for runway 27R and cleared them to land. Shortly after, the flight crew asked the controller if the runway lights for runway 27R could be increased; however, the controller informed them that the lights were already at 100 percent. Just before the controller’s response, the copilot, who was the pilot flying, then asked the captain “where is the runway.” As the flight crew maneuvered to a downwind leg, the captain told the copilot not to go any lower; the copilot requested that the captain tell him when to turn left. The captain told him to turn left about 10 seconds later. The copilot stated, “I see that little mountain, okay” followed by both the captain and co-pilot saying, “woah woah woah, speed, speed” 3 seconds later. During the following 5 seconds, the captain and copilot both stated, “go around the mountain” followed by the captain saying, “this is dicey” and the co-pilot responding, “yeah it’s very dicey.” Shortly after, the captain told the copilot “here let me take it on this turn” followed by the co-pilot saying, “yes, you fly.” The captain asked the copilot to watch his speed, and the copilot agreed. About 1 second later, the copilot stated, “speed speed speed, more more, more more, faster, faster… .” Soon after, the CVR indicated that the airplane impacted the terrain. Automatic dependent surveillance – broadcast (ADS-B) data showed that at the time the flight crew reported the runway in sight, they were about 360 ft below the instrument approach minimum descent altitude (MDA), and upon crossing the published missed approach point they were 660 ft below the MDA. The data showed that the flight overflew the destination airport at an altitude of about 775 ft mean sea level (msl), or 407 ft above ground level (agl), and entered a left downwind for runway 27R. While on the downwind leg, the airplane descended to an altitude of 700 ft msl, then ascended to an altitude of 950 ft msl while on the base leg. The last recorded ADS-B target was at an altitude of 875 ft msl, or about 295 ft agl.
Probable cause:
The flight crew’s decision to descend below the published MDA, cancel their IFR clearance to conduct an unauthorized circle-to-land approach to another runway while the airport was in nighttime IFR conditions, and the exceedance of the airplane’s critical angle of attack, and subsequently entering an aerodynamic stall at a low altitude. Contributing to the accident was the tower crew’s failure to monitor and augment the airport weather conditions as required, due in part to, the placement of the AWOS display in the tower cab and the lack of audible AWOS alerting.
Final Report:

Crash of a Learjet 35A in Belo Horizonte: 1 killed

Date & Time: Apr 20, 2021 at 1452 LT
Type of aircraft:
Registration:
PR-MLA
Flight Type:
Survivors:
Yes
Schedule:
Belo Horizonte - Belo Horizonte
MSN:
35-072
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3432
Captain / Total hours on type:
41.00
Copilot / Total flying hours:
3034
Copilot / Total hours on type:
2211
Circumstances:
The airplane departed Belo Horizonte-Pampulha-Carlos Drummond de Andrade Airport at 1420LT on a local training fight. On board were two pilots and one passenger. After 30 minutes of flight over the area, the crew returned to the airport and initiated the approach to runway 13 to complete a touch and go manoeuvre. On final approach, the crew forgot to lower the gear, causing the airplane to land on its belly. It slid for few hundred metres, overran, went through the perimeter fence (striking concrete poles) and came to rest against trees, broken in two. The copilot aged 76 was killed while both other occupants were injured.
Probable cause:
Contributing factors:
- Attention – undetermined.
It is possible that the aircraft’s encounter with a kite led to a delayed and imprecise response to operational cues, which may have resulted in a breakdown in the alert and distraction management system, specifically regarding landing gear extension.
- Attitude – undetermined.
Conducting the flight with an unqualified pilot reflected the adoption of inappropriate attitudes such as complacency, overconfidence, and disregard for the requirements established in RBACs 91 and 61, which may have contributed to this accident.
- Crew Resource Management – a contributor.
Inefficient use of the human resources available for the aircraft operation led to inadequate task management among the crew. The PIC never questioned the aircraft’s readiness for landing, and the pilot occupying the right seat failed to monitor the aircraft configuration or assertively advise on the landing gear position for touchdown.
- Perception – a contributor.
During the approach, the aural warning indicating that the landing gear was still retracted was activated and could be heard on the CVR audio. However, the pilots took no corrective action, evidencing impaired ability to recognize and interpret internal environmental cues, which led to reduced situational awareness and culminated in a gear up landing.
- Limited pilot’s experience – undetermined.
Considering the PIC’s operational background, developed almost entirely in rotary wing aviation, it is possible that his limited experience with fixed-wing aircraft had not yet enabled him to acquire the full range of skills and knowledge necessary for the safe operation of Learjet 35 flights.
Final Report:

Crash of a Learjet 35 in Santa Marta

Date & Time: Sep 21, 2020
Type of aircraft:
Operator:
Registration:
XA-DOC
Flight Type:
Survivors:
Yes
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing an illegal flight in Central America and was apparently attempting to land on a remote area near Santa Marta. The accident occurred in unclear circumstances and nobody was found in the wreckage. The registration XA-DOC is false and the MSN of the airplane remains unknown.

Crash of a Learjet 35A in Esquel: 3 killed

Date & Time: May 5, 2020 at 2238 LT
Type of aircraft:
Operator:
Registration:
LV-BXU
Flight Type:
Survivors:
Yes
Schedule:
San Fernando – Esquel
MSN:
35-462
YOM:
1982
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1498
Copilot / Total flying hours:
2612
Aircraft flight hours:
11711
Aircraft flight cycles:
10473
Circumstances:
The airplane departed San Fernando Airport on an ambulance flight to Esquel, carrying a doctor, a nurse and two pilots. On approach to Esquel-Brigadier General Antonio Parodi Airport at night, the crew encountered poor visibility (200 metres) and the visual contact with the runway was lost intermittently. Nevertheless, the crew continued the approach and at decision height, the captain decided to continue the descent. After crossing Runway 23 threshold at a height of 78 feet, the pilot-in-command initiated a go-around procedure and turned to the left. The airplane continued in a left hand turn, causing the left wing tip fuel tank to struck the ground. Out of control, the airplane crashed on a small embankment located about 400 metres to the left of the runway centerline, coming to rest upside down and bursting into flames. Both passengers were killed and both pilots were seriously injured. Two days later, the copilot died from injuries sustained.
Probable cause:
It was determined that the accident was the consequence of a controlled flight into terrain (CFIT) and the airplane did not suffer any technical anomalies.
The following contributing factors were identified:
- The crew failed to check the approach charts according to SOP's,
- The approach was initiated and continued in conditions that were below weather minimums,
- Visibility data transmitted by Tower to the crew were inaccurate, leading to confusion on the part of the pilots and their decision-making,
- Both engines were at full power upon impact as the crew was initiating a go-around procedure.
Final Report: