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Last updated: 14 December 2019
Status:Definitief
Datum:vrijdag 15 maart 1991
Tijd:21:07
Type:Silhouette image of generic LJ35 model; specific model in this crash may look slightly different
Learjet 35A
Luchtvaartmaatschappij:Líder Táxi Aéreo
Registratie: PT-LIH
Constructienummer: 35A-433
Bouwjaar: 1981
Motoren: 2 Garrett TFE731-2-2B
Bemanning:slachtoffers: 0 / inzittenden: 2
Passagiers:slachtoffers: 0 / inzittenden: 2
Totaal:slachtoffers: 0 / inzittenden: 4
Schade: Afgeschreven
Gevolgen: Written off (damaged beyond repair)
Plaats:Uberlândia-Eduardo Gomes Airport, MG (UDI) (   Brazilië)
Fase: Nadering (APR)
Soort vlucht:Ambulance
Vliegveld van vertrek:São Paulo-Congonhas Airport, SP (CGH/SBSP), Brazilië
Vliegveld van aankomst:Uberlândia-Eduardo Gomes Airport, MG (UDI/SBUL), Brazilië
Beschrijving:
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:

CONCLUSÃO:

Fator Humano - Aspecto Psicológico - Contribuiu
Houve a participação de variáveis psicológicas, a nível individual e organizacional, que interferiram no desempenho da tripulação, com relação à necessidade da realização do pouso em Uberlândia para o transporte de um paciente.

Fator Operacional
(1). Condições Meteorológicas Adversas - Contribuíram
O aeródromo apresentava condições de teto e visibilidade abaixo dos mínimos.

(2). Deficiente Aplicação dos Comandos - Contribuiu
O piloto não usou os comandos da aeronave adequadamente, permitindo que a mesma estolasse e se chocasse com o solo.

(3). Deficiente Coordenação de Cabine - Indeterminado
Houve uma utilização inadequada dos recursos na cabine destinados à correta operação da aeronave, bem como não observância de normas operacionais.

(4). Deficiente Julgamento - Contribuiu
Houve uma avaliação inadequada, por parte da tripulação, das condições meteorológicas.

(5). Deficiente Planejamento - Contribuiu
A preparação do vôo, com relação ao aspecto meteorológico, foi inadequada.

(6). Deficiente Supervisão - Contribuiu
Houve deficiência na supervisão da atividade aérea, pois um piloto com restrições operacionais foi escalado para voar com um comandante que não era instrutor.

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


Foto's

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

Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen São Paulo-Congonhas Airport, SP en Uberlândia-Eduardo Gomes Airport, MG bedraagt 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.
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