ASN Wikibase Occurrence # 321260
| Date: | Thursday 12 August 2010 |
| Time: | 09:26 |
| Type: |  Learjet 55C |
| Owner/operator: | OceanAir Táxi Aéreo |
| Registration: | PT-LXO |
| MSN: | 55C-135 |
| Year of manufacture: | 1988 |
| Total airframe hrs: | 5530 hours |
| Engine model: | Garrett TFE731-3A-2B |
| Fatalities: | Fatalities: 0 / Occupants: 3 |
| Aircraft damage: | Minor, written off |
| Category: | Accident |
| Location: | Rio de Janeiro-Santos Dumont Airport, RJ (SDU) -
 Brazil
|
| Phase: | Landing |
| Nature: | Executive |
| Departure airport: | Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ) |
| Rio de Janeiro/Galeão-Antonio Carlos Jobim International Airport, RJ (GIG/SBGL) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
A Learjet 55C corporate jet was damaged in a runway excursion accident at Rio de Janeiro-Santos Dumont Airport (SDU). The aircraft ran off the end of runway 02R into the water of Guanabara Bay. The three occupants were not injured.
Approximately two minutes after takeoff from Santos Dumont Airport, the aircraft suffered a voltage drop in the electrical system.
This caused the sequential loss of functionality of various instruments and systems: TCAS, EHSI, EADI, RMI, altimeters and airspeed indicators.
The captain decided to return to the airport, in visual conditions, without declaring an emergency and, following the instructions of the approach controller, started descent to 3,000ft.
Upon reaching the cleared altitude, the pilots lost all communications with ATC. The aircraft was configured for approach and landing and as it aligned with runway 02R, most of the aircraft's instruments and systems became inoperative. The captain decided to continue the approach.
During the landing, the spoilers and reversers of the engines did not work and the aircraft did not show sufficient braking action and overran into Guanabara Bay.
Contributing Factors
1 Human Factor
1.1 Medical Aspect
It did not.
1.2 Psychological Aspect
1.2.1 Individual Information
a) Attention - contributed
The emotional state triggered by the crew in front of the emergency caused the attention to the landing to be fixed, so other important data such as the size of the runway were disregarded.
b) Attitude - contributed
The professional experience of the commander in aviation and in the aircraft itself contributed to overconfidence in his ability, leading him to believe that the decision was the most appropriate and safe for the situation.
c) Emotional state - contributed
The seizure of the crew was triggered by the presence of an unknown emergency, which may have interfered in the decision-making process to the point of not allowing, or even blocking, important data to be considered in the analysis of the situation and in the decision to persist in the landing .
d) Motivation - contributed
The commander persisted in completing the landing, even though there was the possibility of proceeding to the SBGL, thus configuring a compulsion to land. This behavior was possibly influenced by the emotional state experienced by the crew.
e) Perception - contributed
The nervousness of the crew due to the emergency caused a low situational awareness, making it difficult to identify and interpret the various occurrences of loss of functionality of most equipment and instruments.
The immediate decision to return in visual conditions to Santos Dumont airport and landing at this airport, even after the situation worsened, with the loss of functionality of most of the equipment and instruments on board, contributed to the lack of time for pilots to read the emergency section of the check list and correctly assess the situation. During the landing, it was identified that the aircraft would not stop on the runway, but the possibility of going around was not a considered alternative, which shows an inadequate analysis of the situation that contributed to an inadequate decision making.
1.2.2 Psychosocial Information
a) Communication - undetermined
The co-pilot did not explain to the captain his apprehension about the landing at Santos Dumont Airport, due to the reduced size of the runway for the situation, that is, he did not use the assertiveness to warn about a fact that, due to the circumstance experienced, was not being considered appropriately by the commander.
b) Team dynamics - contributed
It was identified that there was not a detailed breakdown of tasks in flight to ensure flight efficiency. The copilot, for example, took on the functions that he thought pertinent. This situation impaired the integration of the team, making it difficult to exchange information and collaboration to carry out the work.
1.2.3 Organizational information
a) Organizational culture - contributed
Due to the lack of standardized operating procedures and the low effectiveness of some training required, it was found that the organizational culture was permeated by informal attitudes, which did not value flight safety and, consequently, affected flight crew performance.
b) Training, Training and Training - contributed
Training is a process that aims at the efficient development of work by the individual. It is through it that habits of thought and action, skills, knowledge and attitudes that enable to carry out activities are improved. As the failure situation of both generators was not trained in the simulator, the crew did not have sufficient ability to correctly interpret the emergency situation.
c) Organization of work - contributed
There were no procedures implemented by the company for the duties that pertain to each function on board, so there is no standardization of the responsibilities to be performed in flight, which may interfere with the division of tasks between the crew in order to ensure that all cabin features are used more efficiently.
d) Organizational processes - indeterminate
The company adopted professional experience as the sole selection criterion. Although this crit
Accident investigation:
 |
|
Sources:
Infraero press release 12/08/2010
Ocean Air diz que os três tripulantes de avião não tiveram ferimentos (G1,
12/08/2010)
Location
Revision history:
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