Date:	Friday 15 March 1991
Time:	21:07
Type:	Learjet 35A
Owner/operator:	Líder Táxi Aéreo
Registration:	PT-LIH
MSN:	35A-433
Year of manufacture:	1981
Engine model:	Garrett TFE731-2-2B
Fatalities:	Fatalities: 0 / Occupants: 4
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	Uberlândia-Eduardo Gomes Airport, MG (UDI) -   Brazil
Phase:	Approach
Nature:	Ambulance
Departure airport:	São Paulo-Congonhas Airport, SP (CGH/SBSP)
Destination airport:	Uberlândia-Eduardo Gomes Airport, MG (UDI/SBUL)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
The Learjet 35A took off from São Paulo (CGH) for Uberlândia (UDI), to pick up a patient there. The co-pilot was pilot flying. It was his first flight on a Learjet without an instructor. This was against regulations since the co-pilot was not fully qualified yet and the captain was not qualified to act as an instructor.
When arriving over Uberlândia, the meteorological conditions were below the minimums due to fog: 8/8 clouds at 100 m and a visibility of 200 m. Two approaches were attempted without success. They should have diverted to another airport, but a third attempt was made, probably because the crew felt pressure to accomplish the flight and pick up the patient. A visual approach was attempted at a low height. A sharp turn was flown during the turn to finals. With a large bank angle a left turn was made for runway 04. The airplane stalled and collided with the ground, skidding 300 m before coming to rest.

CONCLUSION:

Human Factor - Psychological Aspect - Contributed
There was the participation of psychological variables, at individual and organizational level, that interfered in the crew's performance, in relation to the need of landing in Uberlândia for the transportation of a patient.

Operational Factor
(1). Adverse Weather Conditions - Contributed
The aerodrome had ceiling and visibility conditions below the minimum.

(2). Disabled Application of Controls - Contributed
The pilot did not use the aircraft controls properly, allowing it to stall and crash into the ground.

(3). Cabin Coordination Weak - Undetermined
There was an inadequate use of resources in the cabin intended for proper operation of the aircraft, as well as failure to comply with operating standards.

(4). Disabled Judgement - Contributed
There has been an inadequate assessment by the crew of the weather conditions.

(5). Poor Planning - Contributed
The flight preparation, with regard to the meteorological aspect, was inadequate.

(6). Disabled Supervision - Contributed
There was a deficiency in the supervision of the air activity, because a pilot with operational restrictions was climbed to fly with a commander who was not an instructor.

CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos

photo (c) Werner Fischdick; Rio de Janeiro-Santos Dumont Airport, RJ (SDU); 05 January 1990

Date/time	Contributor	Updates
15-Mar-2024 19:57	ASN	Updated [Accident report]