Statuts: | Accident investigation report completed and information captured |
Date: | dimanche 23 mars 2003 |
Heure: | 11:25 |
Type/Sous-type: | Mitsubishi Mu-300 Diamond IA |
Compagnie: | Chubb do Brasil Companhia de Seguros |
Immatriculation: | PT-LNN |
Numéro de série: | A048SA |
Année de Fabrication: | 1982 |
Equipage: | victimes: 0 / à bord: 2 |
Passagers: | victimes: 0 / à bord: 1 |
Total: | victimes: 0 / à bord: 3 |
Dégats de l'appareil: | Perte Totale |
Conséquences: | Written off (damaged beyond repair) |
Lieu de l'accident: | Santos Air Base, SP (SSZ) ( Brésil)
|
Phase de vol: | A l'atterrissage (LDG) |
Nature: | Affaires |
Aéroport de départ: | Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ), Brésil |
Aéroport de destination: | Santos Air Base, SP (SSZ/SBST), Brésil |
Détails:After an aborted NDB descent, the aircraft went around for a new attempt, reaching VFR conditions with runway 35 (asphalt, 1390 m long). There were large and medium cloud formations in the area. A tailwind landing was attempted. After landing, the pilot lost control and the aircraft went off the end of the runway. After crossing the concrete breakwater it ran into the Canal de Bertioga and sank, suffering serious damage. The occupants escaped unhurt.
Probable Cause:
Contributing Factors: (translated from official report)
1 Human Factor
1.1 Medical Aspect
Not searched.
1.2 Psychological Aspect
Not searched.
1.2.1 Individual Information
Nothing to report.
1.2.2 Psychosocial Information
Nothing to report.
1.2.3 Organizational Information
Nothing to report.
1.3 Operational Aspect
1.3.1 Concerning the operation of the aircraft
a) Adverse weather conditions - contributed
Heavy rain, low ceiling, around 800 feet, and visibility restrictions, approximately 2,500 meters, contributed to the occurrence.
b) Forgetting the pilot - undetermined
It is possible that the pilot forgot to use emergency brake features, which if used with discretion, could minimize the difficulties faced to stop the aircraft at the edge of the runway.
c) Pilot Trial - contributed
The crew judged that the present conditions would allow a safe landing at the aerodrome of Santos Air Base.
d) Low pilot experience - undetermined
The pilot and co-pilot had little experience of flying in the aircraft. It is likely that this contributed to the inadequate judgment of the landing conditions.
e) Other - contributed
In spite of the initiative to perform 360 degrees circle, to lose height, the pilot ended up positioned high and fast for the landing, which caused the touch down at 450 meters from the threshold of runway 35 and the exiting of the runway.
1.3.2 Concerning ATS
Did not contribute.
2 Material Factor
2.1 Concerning the aircraft
Did not contribute.
2.2 Concerning equipment and technology systems for ATS
Did not contribute.
Accident investigation:
|
Investigating agency: | CENIPA Brazil |
Status: | Investigation completed |
Duration: | 8 years and 9 months | Accident number: | RF A-104/CENIPA/2011 | Download report: | Final report
|
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Sources:
» Departamento de Aviação Civil (DAC)
Opérations de secours
CENIPA issued 2 Safety Recommendations
Issued: 23-MAY-2005 | To: | RSV (A) 38 / 2005 - SERAC 4 |
Elaborar DIVOP encaminhando-a para escolas de aviação, aeroclubes, empresas de táxi-aéreo, sindicatos e associações sediadas na área de jurisdição, bem como aos demais SERAC, enfatizando a necessidade de implementar o treinamento de CRM e o Programa "Approach and Landing Accidenl Reducion" - ALAR, levando em consideração os fatos registrados neste RELIAA. |
Issued: 21-DEC-2011 | To: | RSV (A) 367/2011 - CENIPA |
Adotar mecanismos de divulgação dos ensinamentos colhidos na presente investigação aos operadores de Táxi-Aéreo, alertando quanto aos riscos decorrentes da tentativa de pousar em condições desfavoráveis. |
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Photos
accident date:
23-03-2003type: Mitusbishi Mu-300 Diamond 1A
registration: PT-LNN
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 Rio de Janeiro-Santos Dumont Airport, RJ et Santos Air Base, SP est de 337 km (211 miles).
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.