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Last updated: 11 December 2018
Status:Final
Date:Friday 16 September 2005
Time:14:05
Type:Silhouette image of generic C525 model; specific model in this crash may look slightly different
Cessna 525 CitationJet
Operator:Viação Cometa
Registration: PT-WLX
C/n / msn: 525-0176
First flight: 1997
Total airframe hrs:2231
Engines: 2 Williams International FJ44-1A
Crew:Fatalities: 2 / Occupants: 2
Passengers:Fatalities: 0 / Occupants: 0
Total:Fatalities: 2 / Occupants: 2
Aircraft damage: Damaged beyond repair
Location:Alto da Boa Vista, RJ (   Brazil)
Phase: Initial climb (ICL)
Nature:Ferry/positioning
Departure airport:Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ), Brazil
Destination airport:Rio de Janeiro-Jacarepaguá Airport, RJ (SBJR), Brazil
Narrative:
After departure from Santos Dumont Airport, the CitationJet climbed to a height of 1,500 feet and maintained this altitude. The pilot crossed the line of Gávea Rock and informed the Jacarepaguá tower he was following the coastal route. Shortly afterward the airplane crashed into the wooded slope of Morro da Taquara, near Alto da Boa Vista, and was totally destroyed. Both occupants were killed.

Probable Cause:

Contributing Factors (translated from Portuguese language report)
1 Human Factor
Medical aspect
Did not contribute.
Psychological aspect - Contributed
The decision of the crew to continue the visual flight under adverse weather conditions and near a mountainous region was, according to the operational aspect, one of the contributing factors for the occurrence of the accident. Linked to this decision making, it is assumed that there are some other factors, among them, the excess of confidence in the equipment and familiarity with the route. These, in turn, may have favored the increased self-confidence of the pilots in their operational performances, as well as the feeling of invulnerability, leading them to a devaluation of the risk situation in which they were. Another aspect concerns the complacency among pilots, in the face of decision-making, possibly because of the degree of affinity and friendship that both had.
Operational aspect
a. Adverse weather conditions - Contributed
Although the information in the METAR of the time did not report significant adverse conditions that would prevent VFR flight in the proposed route, that day, the entrance of a front in the TMA-RJ, that significantly altered the conditions prevailing in the area of SBJR, at the moment of the accident.
In the vicinity of Pedra da Gávea and Alto da Boa Vista, which are mountainous regions, conditions had deteriorated even more rapidly. Witnesses report that the ceiling was quite restricted in that locality at the time of the accident in question.
b. Education - Contributed
Due to the operating characteristic of the TPP aircraft, RBHA 91 does not establish the obligation to prepare a Crew Training Program, including simulator sessions, even if the aircraft are considered high performance.
c. Judgment - Contributed
According to the CVR records, there is an erroneous decision-making of the crew, when proceeding in visual flight under adverse weather conditions. At no point was there any initiative by the crew to return to SBRJ or modify flight rules for IFR.
There is an inadequate evaluation of the distance to SBJR, which led the crew to fly to the right of the correct position of the wind leg and to an altitude below the minimum to clear the existing obstacles.
d. Cockpit Coordination - Contributed
Prior to take-off, a critical flight phase, which requires the crew to be attentive and comply with certain procedures, such as conducting the briefing and checking list (check list), prevailing non-activity conversations in the cabin of flight. This attitude, repeated during the other phases of the operation, revealed a complacency between the pilots in the decision making. This signals a predominance of an interpersonal relationship, friendly and relaxed, to the detriment of a professional relationship, more focused on standardization and proper execution of flight procedures.
e. Planning - Contributed
Although the METAR of the time did not report significant adverse weather conditions that made it impossible to fly under VFR conditions en route, it was possible to infer that a briefing was not carried out based on the analysis of the information available at that moment for the accomplishment of the mission .
f. Supervision - Contributed
The operating company has a solid tradition in the market and certainly presents a well developed safety culture in the field of road transport. However, there is a lack of experience in the aeronautical field. Due to this, it is assumed that the culture of flight, little developed, has facilitated the existence of behaviors and procedures incompatible with flight safety.
Regarding the process of supervision of the pilots, there was no basis on the part of the company to charge its pilots for compliance with norms that regulate air activity. In view of the above, it is believed that the Organization, due to the almost non-existent aeronautical culture and the fragile culture of flight safety, allowed the predominance of decisions taken from individual visions (of the crew), instead of those based on standardized definitions, clearly their operational staff.
g. Flight Discipline - Contributed
The IMA 100-12 establishes the general, obligatory criteria for the performance of a flight in visual conditions. Certainly, at that time, the pilots did not observe these criteria when entering in meteorological conditions by instruments, being under rules of visual flight.
2 Material factor
Did not contribute.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 3 years and 7 months
Accident number: RF A 025/CENIPA/2009
Download report: Final report

Classification:
VFR flight in IMC
Controlled Flight Into Terrain (CFIT) - Mountain

Sources:
» DAC - Departamento de Aviação Civil: Acidentes aeronáuticos ocorridos em 2005


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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Rio de Janeiro-Santos Dumont Airport, RJ to Rio de Janeiro-Jacarepaguá Airport, RJ as the crow flies is 22 km (14 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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