Narrative:
The Learjet 31A suffered a runway excursion after landing on runway 03 at Diamantina Airport, Brazil. It went down a dropoff.
The aircraft was operating an ambulance flight to pick up a Covid-19 patient.
Diamantina Airport has a single asphalt runway (03/21), measuring 1610 x 30 m. Past the paved runway surface of runway 03 there is a 60 m stopway, followed by downsloping terrain.
Contributing factors:
- Application of controls - contributed.
Considering that the distance ahead of the aircraft at the moment of touchdown (600 m) was not sufficient to decelerate and stop the plane within the runway limits, it was found that an inadequacy in the use of flight controls led to a long landing, where, from the touchdown point, there was not enough runway to safely stop the aircraft.
- Attitude - undetermined.
The fact that the PIC (PM) had already conducted several flights with the SIC (PF) without any issues, as well as their close relationship, may have contributed to an attitude of excessive confidence and resulted in a non-assertive perception of the approach parameters during this phase of the flight.
- Cockpit coordination - contributed.
The account of the events leading up to the landing indicated that the available human resources for aircraft operation were not adequately utilized, as the PIC (PM) only noticed the deviations that led to this runway excursion on short final, characterizing inefficient cockpit coordination as a contributing factor to the studied accident.
- Fatigue - undetermined.
Based on the medical examinations conducted after the accident, as well as the overall picture observed by the medical representative, it was inferred that the lack of response from the SIC (PF) to the PIC's (PM) alerts and impairment to his alertness could be indicative of the pilot experiencing fatigue-related effects that may have interfered with his performance.
- Perception - contributed.
The attempt to land even in the face of an unstable approach characterized an inadequate perception of the risks involved in continuing this procedure under the experienced conditions.
- Pilot judgment - contributed.
The decision to proceed with the landing, even after conducting an unstable approach to a position where only 600 m of runway would remain for the aircraft to stop, as well as the failure to consider the alternative of a go-around, characterized an inadequate judgment regarding the risks of the operation conducted under the circumstances.
» itatiaia.com.br
accident date: 02-01-2021
type: Learjet 31A
registration: PP-BBV
accident date: 02-01-2021
type: Learjet 31A
registration: PP-BBV
| Status: | Accident investigation report completed and information captured |
| Date: | Saturday 2 January 2021 |
| Time: | 11:51 UTC |
| Type: |  Learjet 31A |
| Operator: | Brasil Vida Táxi Aéreo |
| Registration: | PP-BBV |
| MSN: | 31-113 |
| First flight: | 1995 |
| Engines: | 2 Garrett TFE731 |
| Crew: | Fatalities: 0 / Occupants: 2 |
| Passengers: | Fatalities: 0 / Occupants: 2 |
| Total: | Fatalities: 0 / Occupants: 4 |
| Aircraft damage: | Substantial |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | Diamantina Airport, MG (DTI) ( Brazil)
|
| Phase: | Landing (LDG) |
| Nature: | Ambulance |
| Departure airport: | São Paulo-Congonhas Airport, SP (CGH/SBSP), Brazil |
| Diamantina-Juscelino Kubitschek Airport, MG (DTI/SNDT), Brazil |
The Learjet 31A suffered a runway excursion after landing on runway 03 at Diamantina Airport, Brazil. It went down a dropoff.
The aircraft was operating an ambulance flight to pick up a Covid-19 patient.
Diamantina Airport has a single asphalt runway (03/21), measuring 1610 x 30 m. Past the paved runway surface of runway 03 there is a 60 m stopway, followed by downsloping terrain.
Probable Cause:
Contributing factors:
- Application of controls - contributed.
Considering that the distance ahead of the aircraft at the moment of touchdown (600 m) was not sufficient to decelerate and stop the plane within the runway limits, it was found that an inadequacy in the use of flight controls led to a long landing, where, from the touchdown point, there was not enough runway to safely stop the aircraft.
- Attitude - undetermined.
The fact that the PIC (PM) had already conducted several flights with the SIC (PF) without any issues, as well as their close relationship, may have contributed to an attitude of excessive confidence and resulted in a non-assertive perception of the approach parameters during this phase of the flight.
- Cockpit coordination - contributed.
The account of the events leading up to the landing indicated that the available human resources for aircraft operation were not adequately utilized, as the PIC (PM) only noticed the deviations that led to this runway excursion on short final, characterizing inefficient cockpit coordination as a contributing factor to the studied accident.
- Fatigue - undetermined.
Based on the medical examinations conducted after the accident, as well as the overall picture observed by the medical representative, it was inferred that the lack of response from the SIC (PF) to the PIC's (PM) alerts and impairment to his alertness could be indicative of the pilot experiencing fatigue-related effects that may have interfered with his performance.
- Perception - contributed.
The attempt to land even in the face of an unstable approach characterized an inadequate perception of the risks involved in continuing this procedure under the experienced conditions.
- Pilot judgment - contributed.
The decision to proceed with the landing, even after conducting an unstable approach to a position where only 600 m of runway would remain for the aircraft to stop, as well as the failure to consider the alternative of a go-around, characterized an inadequate judgment regarding the risks of the operation conducted under the circumstances.
Accident investigation:
|
Classification:
Runway excursion (overrun)
Sources:
» g1.globo.com» itatiaia.com.br
Follow-up / safety actions
CENIPA issued 1 Safety Recommendation
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Photos
accident date: 02-01-2021
type: Learjet 31A
registration: PP-BBV
accident date: 02-01-2021
type: Learjet 31A
registration: PP-BBV
Video, social media
Acidente com aeronave deixa três feridos em aeroporto de Diamantina https://t.co/8U9sevk0LM
— Por Dentro de Minas (@pordentrodemg) January 2, 2021
Foto: Divulgação/Corpo de Bombeiros pic.twitter.com/V9wMeq5gBD
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 São Paulo-Congonhas Airport, SP to Diamantina-Juscelino Kubitschek Airport, MG as the crow flies is 674 km (421 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from São Paulo-Congonhas Airport, SP to Diamantina-Juscelino Kubitschek Airport, MG as the crow flies is 674 km (421 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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