ASN logo
Last updated: 6 August 2020
Status:Final
Date:Friday 15 March 1991
Time:21:07
Type:Silhouette image of generic LJ35 model; specific model in this crash may look slightly different
Learjet 35A
Operator:Líder Táxi Aéreo
Registration: PT-LIH
C/n / msn: 35A-433
First flight: 1981
Engines: 2 Garrett TFE731-2-2B
Crew:Fatalities: 0 / Occupants: 2
Passengers:Fatalities: 0 / Occupants: 2
Total:Fatalities: 0 / Occupants: 4
Aircraft damage: Damaged beyond repair
Location:Uberlândia-Eduardo Gomes Airport, MG (UDI) (   Brazil)
Phase: Approach (APR)
Nature:Ambulance
Departure airport:São Paulo-Congonhas Airport, SP (CGH/SBSP), Brazil
Destination airport:Uberlândia-Eduardo Gomes Airport, MG (UDI/SBUL), Brazil
Narrative:
The Learjet 35A took off from São Paulo (CGH) for Uberlândia (UDI), to pick up a patient there. The co-pilot was pilot flying. It was his first flight on a Learjet without an instructor. This was against regulations since the co-pilot was not fully qualified yet and the captain was not qualified to act as an instructor.
When arriving over Uberlândia, the meteorological conditions were below the minimums due to fog: 8/8 clouds at 100 m and a visibility of 200 m. Two approaches were attempted without success. They should have diverted to another airport, but a third attempt was made, probably because the crew felt pressure to accomplish the flight and pick up the patient. A visual approach was attempted at a low height. A sharp turn was flown during the turn to finals. With a large bank angle a left turn was made for runway 04. The airplane stalled and collided with the ground, skidding 300 m before coming to rest.

Probable Cause:

CONCLUSION:

Human Factor - Psychological Aspect - Contributed
There was the participation of psychological variables, at individual and organizational level, that interfered in the crew's performance, in relation to the need of landing in Uberlândia for the transportation of a patient.

Operational Factor
(1). Adverse Weather Conditions - Contributed
The aerodrome had ceiling and visibility conditions below the minimum.

(2). Disabled Application of Controls - Contributed
The pilot did not use the aircraft controls properly, allowing it to stall and crash into the ground.

(3). Cabin Coordination Weak - Undetermined
There was an inadequate use of resources in the cabin intended for proper operation of the aircraft, as well as failure to comply with operating standards.

(4). Disabled Judgement - Contributed
There has been an inadequate assessment by the crew of the weather conditions.

(5). Poor Planning - Contributed
The flight preparation, with regard to the meteorological aspect, was inadequate.

(6). Disabled Supervision - Contributed
There was a deficiency in the supervision of the air activity, because a pilot with operational restrictions was climbed to fly with a commander who was not an instructor.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Accident number: final report
Download report: Final report

Classification:

VFR flight in IMC
Loss of control

Sources:
» CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos


Photos

photo of Learjet-35A-PT-LIH
accident date: 15-03-1991
type: Learjet 35A
registration: PT-LIH
 

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 Uberlândia-Eduardo Gomes Airport, MG as the crow flies is 550 km (344 miles).

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.
languages: languages

Share