Accident Learjet 24D PT-LEM,
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ASN Wikibase Occurrence # 323765
 

Date:Wednesday 7 April 1999
Time:11:47
Type:Learjet 24D
Owner/operator:Manacá Táxi Aéreo
Registration: PT-LEM
MSN: 24-270
Year of manufacture:1973
Engine model:General Electric CJ610-6
Fatalities:Fatalities: 5 / Occupants: 5
Aircraft damage: Destroyed, written off
Category:Accident
Location:Ribeirão Preto-Leite Lopes Airport, SP (RAO) -   Brazil
Phase: Landing
Nature:Training
Departure airport:São Paulo-Congonhas Airport, SP (CGH/SBSP)
Destination airport:Ribeirão Preto-Leite Lopes Airport, SP (RAO/SBRP)
Investigating agency: CENIPA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
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.

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:
cover
  
Investigating agency: CENIPA
Report number: final report
Status: Investigation completed
Duration:
Download report: Final report

Sources:

DAC - Departamento de Aviação Civil

Location

Revision history:

Date/timeContributorUpdates
15-Mar-2024 19:53 ASN Updated [Accident report]

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