Date & Time:
Apr 6, 1990 at 1503 LT
Type of aircraft:
Learjet 25
Operator:
Transamérica Táxi Aéreo
Registration:
PT-CMY
Flight Phase:
Landing (descent or approach)
Flight Type:
Cargo
Survivors:
Yes
Schedule:
Rio de Janeiro – Juiz de Fora – Belo Horizonte – Monte Carlos
MSN:
25-108
YOM:
1973
Country:
Brazil
Region:
South America
Crew on board:
2
Crew fatalities:
1
Pax on board:
2
Pax fatalities:
1
Other fatalities:
0
Total fatalities:
2
Captain / Total hours on type:
225
Copilot / Total hours on type:
9
Circumstances:
The airplane departed Rio de Janeiro-Santos Dumont Airport at 1440LT on a cargo flight to Monte Carlos with intermediate stops in Juiz de Fora and Belo Horizonte, carrying two passengers, two pilots and a load of bank notes. Because the crew failed to prepare the flight according to procedures, the aircraft departed Santos Dumont with a total weight in excess of 711 kilos. Following a poor flight and approach planning, the crew failed to make the appropriate landing calculations and upon arrival, the total weight of the aircraft was 946 kilos above the max landing weight. The aircraft landed on wet runway 21 and after touchdown, the spoilers did not deployed. Unable to stop within the remaining distance, the aircraft overran, went down a 20 metres ravine and came to rest, bursting into flames. The captain and a passenger were killed while both other occupants were injured. The aircraft was destroyed.
Probable cause:
The following contributing factors were identified:
• Human Factor - Psychological Aspect - It contributed to the occurrence of the accident due to managerial failures, allowing an aircraft to be used improperly and assigning pilots without the necessary training and experience.
• Deficient Instruction - There are indications that it contributed. Given the errors committed in conducting the flight, regarding incorrect and deficient planning, lack of knowledge or disregard for the limitations of the aircraft, considering the conditions existing at the time of the accident, it is believed that there was deficient instruction during the transition phase from other equipment to this one.
• There was inadequate follow-up during the instruction given to the student, due to the failure to complete the flight evaluation forms.
• Poor Cockpit Coordination - the copilot, by participating in the landing operation merely as a spectator, undeniably demonstrates poor coordination among the crew.
• Poor Judgment - the decision to perform the landing under the existing conditions at the time of the accident (wet runway, excess weight, center of gravity outside limits, etc.) demonstrates a completely deficient judgment on the part of the captain. At the time of the accident, runway 03/21 was 1,303 metres long and in light of the above elements, a distance of 3,285 metres was required for the plane to land.
• Poor Planning - this was the determining factor in the occurrence of the accident, as the failure in weight and balance calculations, as well as incorrect loading, culminated in the loss of control during the landing operation, since the aircraft exceeded all operational limits at that moment.
• Deficient Supervision - despite the commander having extensive flight experience, the number of flight hours on the aircraft type proved insufficient for the role of commander, as the data collected during the investigation showed that he did not possess the necessary technical knowledge, compromising his decisions as commander. The copilot, in turn, was still in training. What the pilot knew concretely, in relation to the mission he was to execute, was only the route to be flown. These aspects are consistent with serious supervision failures and the absence of flight safety doctrine in the company.
• Human Factor - Psychological Aspect - It contributed to the occurrence of the accident due to managerial failures, allowing an aircraft to be used improperly and assigning pilots without the necessary training and experience.
• Deficient Instruction - There are indications that it contributed. Given the errors committed in conducting the flight, regarding incorrect and deficient planning, lack of knowledge or disregard for the limitations of the aircraft, considering the conditions existing at the time of the accident, it is believed that there was deficient instruction during the transition phase from other equipment to this one.
• There was inadequate follow-up during the instruction given to the student, due to the failure to complete the flight evaluation forms.
• Poor Cockpit Coordination - the copilot, by participating in the landing operation merely as a spectator, undeniably demonstrates poor coordination among the crew.
• Poor Judgment - the decision to perform the landing under the existing conditions at the time of the accident (wet runway, excess weight, center of gravity outside limits, etc.) demonstrates a completely deficient judgment on the part of the captain. At the time of the accident, runway 03/21 was 1,303 metres long and in light of the above elements, a distance of 3,285 metres was required for the plane to land.
• Poor Planning - this was the determining factor in the occurrence of the accident, as the failure in weight and balance calculations, as well as incorrect loading, culminated in the loss of control during the landing operation, since the aircraft exceeded all operational limits at that moment.
• Deficient Supervision - despite the commander having extensive flight experience, the number of flight hours on the aircraft type proved insufficient for the role of commander, as the data collected during the investigation showed that he did not possess the necessary technical knowledge, compromising his decisions as commander. The copilot, in turn, was still in training. What the pilot knew concretely, in relation to the mission he was to execute, was only the route to be flown. These aspects are consistent with serious supervision failures and the absence of flight safety doctrine in the company.
Final Report:
PT-CMY.pdf1.35 MB
