Statuts: | Accident investigation report completed and information captured |
Date: | mercredi 7 avril 1999 |
Heure: | 11:47 |
Type/Sous-type: | Learjet 24D |
Compagnie: | Manacá Táxi Aéreo |
Immatriculation: | PT-LEM |
Numéro de série: | 24-270 |
Année de Fabrication: | 1973 |
Moteurs: | 2 General Electric CJ610-6 |
Equipage: | victimes: 3 / à bord: 3 |
Passagers: | victimes: 2 / à bord: 2 |
Total: | victimes: 5 / à bord: 5 |
Dégats de l'appareil: | Perte Totale |
Conséquences: | Written off (damaged beyond repair) |
Lieu de l'accident: | Ribeirão Preto-Leite Lopes Airport, SP (RAO) ( Brésil)
|
Phase de vol: | A l'atterrissage (LDG) |
Nature: | Entrainement |
Aéroport de départ: | São Paulo-Congonhas Airport, SP (CGH/SBSP), Brésil |
Aéroport de destination: | Ribeirão Preto-Leite Lopes Airport, SP (RAO/SBRP), Brésil |
Détails:The Learjet operated on a training flight from São Paulo to Ribeirão Preto where the pilot was to conduct a revalidation of his pilot's license.
The flight crew conducted an NDB approach for a touch and go on runway 18 at Ribeirão Preto Airport. Just before touchdown, the aircraft banked right, causing the right hand wing tip tank to touch the runway. The pilot overcorrected, causing the aircraft to roll to the left to an inverted position. The aircraft impacted the runway and burst into flames.
It appeared that the pilot was used to flying Citation II jets and had very limited experience in Learjet 24D aircraft as copilot. Also, he had not flown for the last four months. The pilot's behavior showed excessive self-confidence, according to investigators.
Probable Cause:
Contributing Factors (translated from Portuguese):
a. Human Factor
Psychological - Contributed.
There was the participation of individual psychological variables in the pilot in command's performance , due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
b. Operational Factor
(1). Deficient Supervision - Contributed
There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
(2).Low Flight Experience in the Aircraft - Contributed
The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
(3). Deficient Cockpit Coordination - Contributed.
The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
(4). Deficient Application of Commands - Contributed.
The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
(5). Other Operational Aspects - Contributed
The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.
Accident investigation:
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Investigating agency: | CENIPA Brazil |
Status: | Investigation completed |
Accident number: | final report | Download report: | Final report
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Sources:
» DAC - Departamento de Aviação Civil
Photos
Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre São Paulo-Congonhas Airport, SP et Ribeirão Preto-Leite Lopes Airport, SP est de 299 km (187 miles).
Accident location: Approximate; accuracy within a few kilometers.
Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.